American Circumcision, a that fires a double-barrelled blast at the procedure, opens with close-ups of an infant being wheeled into a large operating theater with a tray of shiny, sharp surgical instruments, then strapped into a restraint device.
Obviously, the baby did not grant consent for this irreversible surgery performed for usually non-medical and even hazy reasons. MedPage Today contacted physicians and ethicists to discuss the film and the perhaps irresolvable controversy over circumcision.
Brian Earp, BA, MSc, MPhil, associate director of the Yale-Hastings Program in Ethics and Health Policy in New Haven, Connecticut, entitled "Cultural Bias in American Medicine: The Case of Infant Male Circumcision," summarized the ethical problem in an email to MedPage Today.
Because babies cannot consent to anything, parents are entrusted to make decisions based on what they think is in the best interests of the child. But "[this] does not give parents a blank check to authorize whatever permanent bodily modifications they may choose," he said in an email to MedPage Today.
"Permanently removing sensitive tissue the child may later see as valuable from the most private part of their body goes far beyond mere touching and is a serious violation of the child's rights (that is, their right to have such permanent, personal decisions left to them when they do become autonomous)," Earp wrote.
In general, the film's take on circumcision matches that of the "Intactivists" who protest at medical meetings, such as the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG). In their view, all forms of circumcision are wrong; the procedure is simply the male version of genital mutilation.
Organized medicine in general has tried to keep its distance from the controversy. When contacted about the documentary by MedPage Today, the AAP said, "we are not aware of any of our spokespeople who have watched this movie."
However, the group did issue a policy statement in 2012 about circumcision, offering a "permissive" recommendation for the procedure, citing potential health benefits of fewer urinary tract infections and reduced risk of sexually transmitted infections as outweighing the "relatively small risks" of the procedure.
"Parents ultimately should decide whether circumcision is in the best interests of their male child. They will need to weigh medical information in the context of their own religious, ethical, and cultural beliefs and practices. The medical benefits alone may not outweigh these other considerations for individual families," the AAP statement concluded.
Most people know that infant circumcision is, for many people, a religious ritual -- deeply rooted in Jewish and Muslim traditions, but also common among Christians. It is also simply habitual for many Americans in whose families it has always been practiced for reasons that are no longer clear.
One U.S. physician appearing in the film is Andrew Freedman, MD, who said he circumcised his own son. He did it "because for me, that's my tribe. I'm not saying you should do it.... I want you to do what's right for you."
On the other hand, according to Earp, 38 senior European physicians including heads and representatives of national medical societies wrote a rebuttal to the AAP's statement. The Canadian Pediatric Society, the Canadian Urological Association, the Royal Australasian College of Physicians and the Royal Dutch Medical Association have also come out against the AAP's position, he said.
George Rutherford, MD, of the University of California San Francisco, urged the medical field to "be a little more circumspect about circumcision" in an email to MedPage Today.
"In the U.S, the case is not particularly clear one way or the other," he said. "In sub-Saharan Africa and a few other high prevalence countries, the evidence is clear because of the risk of HIV."
'Circumcision to Prevent AIDS Agenda'
But American Circumcision does not stop with infant circumcision -- it's also critical of the procedure among adult African men who agree to it as a way to reduce risk of HIV infection. This despite randomized controlled trials of young men that found significant reductions in risk of acquiring HIV.
Marilyn Milos, RN, founder of the anti-circumcision group NOCIRC, warns darkly in the film of an "agenda with big, big bucks behind it" -- funders include the Bill and Melinda Gates Foundation, as well as PEPFAR. American Circumcision tries to raise questions about "statistical shortcuts" in those trials.
For example, the head of a group called Doctors Opposing Circumcision, says the 1.8 percentage-point absolute risk reduction between groups is "the number you should be reading in your newspapers," not the 53% relative risk reduction.
Robert Bailey, PhD, professor of public health at the University of Illinois in Chicago, and a principal investigator on one of the NIH-funded trials, told MedPage Today that he is sympathetic to the conclusion that infant circumcision is an assault on children's rights. But in Africa, circumcisions are done to prevent HIV acquisition in adolescents and adults who are able to give consent.
Craig Cohen, MD, professor of the department of obstetrics, gynecology and reproductive sciences at the University of California San Francisco, summarized the theory behind circumcision to reduce risk of HIV in high prevalence nations: that HIV targets specific cells found in higher concentration in the inner portion of the foreskin. Removing the foreskin then removes these target cells and the risk of the build-up of smegma, which can cause inflammation -- and can activate these cells that are more likely to be targeted by HIV.
Cohen also lived in Kenya from 1994 to 2002 and worked in Western Kenya among an ethnic group called the Luo, which did not practice cultural circumcision and was an "ethnic group hit hardest by the HIV epidemic."
"In a setting like Kenya or South Africa with a high prevalence of HIV, my personal view is that it makes sense as a public health intervention to reduce the spread of HIV and other infections," he told MedPage Today.
Cohen also pointed out that the trials were stopped early because "evidence became so overwhelming statistically that ... it would've been unethical to continue the control arm of trial."
"When you look at consistency, these three trials are in lock-step with each other," he said. "As a researcher or policy-maker, you can't ask for more evidence than that."
Bailey refuted the film's attempt to minimize the effectiveness of voluntary circumcision. "Over tens of thousands of circumcisions, we might prevent one HIV infection per 12 circumcisions, or in a high incidence area, it could be as few as 6 circumcisions per HIV infection averted," he said.
Although the documentary suggests a movement is underway to promote adult circumcision in the U.S. for HIV prevention, Bailey questioned whether anyone would be in favor of it. The vast majority of new HIV infections in the U.S. are among men who have sex with men and persons who inject drugs -- neither of whom would benefit from circumcision.
Cohen added that the debate on infant circumcision should be "dissociated from the HIV studies that have done very well and not try to negatively influence the countries that have invested a lot of energy" into these programs.