By Brian D. Earp

See Brian’s most recent previous post by clicking here.

See all of Brian’s previous posts by clicking here.

UPDATED as of 27 May, 2013. See the bottom of the post.

For the first time in over a decade, the American Academy of Pediatrics (AAP) has revised its policy position on infant male circumcision. They now state that the probabilistic health benefits conferred by the procedure outweigh the known risks and harms. Not enough to positively recommend circumcision (as some media outlets are erroneously reporting), but just enough to suggest that whenever it is performed—for cultural or religious reasons, or sheer parental preference, as the case may be—it should be covered by government health insurance.

That turns out to be a very fine line to dance on. The AAP position statement is characterized by equivocations, hedging, and uncertainty; and the longer report upon which it is based includes a number of non-sequiturs, instances of self-contradiction, and cherry-picking of essential evidence (see analysis below).

The AAP appears to be out of tune with world opinion on this issue. On a global scale, medical authorities remain skeptical about whether circumcision of male minors confers any – let alone significant – net health benefits. Indeed, child health experts in Britain, Germany, Scandinavia, Australia, New Zealand, Canada, and elsewhere are predominately of the view that non-therapeutic circumcision (NTC) confers no meaningful health benefits on balance (considered against drawbacks, harms, and risks), and that it should be neither recommended to parents nor funded by health insurance systems.

Nota bene: these cosmopolitan physicians and the medical boards on which they sit have access to the very same data as the AAP. They just don’t draw the same conclusions.

In view of this empirical uncertainty on the medical question, it is problematic to assert, as the AAP does in its new report, that a person does not retain the right to decide whether he wishes to keep his own healthy foreskin–and thus preserve his genitals intact–and that the right belongs instead to his parents.

Parental rights

On the question of parental rights, a point of comparison is frequently raised, including the example of ear-piercing for little girls. Don’t parents have a right to do that? And how is circumcision any different?

There are two ways to respond to the ear-piercing example (and these responses may serve as templates for other comparable interventions). The first way is to suggest that perhaps ear-piercing, too, should not be permitted before the child herself can weigh in on whether or not she would like to have her own ears pierced. If she understands that it will be painful, that there are certain risks involved, and so on, and yet it’s still something she’d like to undertake, then so be it.

The second, stronger way, is to point out that the two practices—ear-piercing and infant male circumcision—are not remotely commensurate, neither in terms of the interventions themselves, nor their effects. Ear-piercing removes no tissue, does not threaten any bodily function, can be tolerated without anesthesia, and is reversible: the hole will close up over time if the child decides later on that she would like to have her earlobes hole-free.

By contrast, male circumcision removes up to half of the skin system of the penis, eliminates the motile and protective functions of the foreskin, cannot be tolerated without anesthesia, and is irreversible: anyone who resents having had his foreskin removed can never get it back.

Given, then, the substantial differences between ear-piercing and male circumcision—in terms of both the interventions themselves and their necessary (i.e., not just accidental or probabilistic) effects—that are directly relevant to the moral calculus involved in assessing their respective permissibility, much more work would be needed to establish that there is any kind of parity of reasoning between them.

Indeed, those who are skeptical about the ethical soundness of ablating the foreskin in infancy are not typically suggesting that any intervention that breaks the skin of any child at any age—regardless of the level of risk involved, and regardless of the diminishing effects on function, and regardless of the reversibility of the procedure, and regardless of the child’s having had an opportunity to give some input as to the desirability of the intervention—should be considered ethically dubious. Rather, it is precisely the level of harm involved, the degree of functional diminishment, the irreversibility, the impossibility of attaining any input from the person whose body (indeed whose penis) is to be permanently surgically altered, and so on, that mark out infant male circumcision as a specially problematic practice.

Parents can of course give proxy consent for needful therapeutic procedures aimed at treating a known pathology. That is, if the pathology presents a genuine threat to the child, and if the intervention cannot be delayed until the child understands what is at stake, and if there are not safer, more reliable, more effective alternative treatments. A healthy foreskin, however, is not a pathology. It needs no treatment at all. To remove it, therefore, on grounds of “proxy consent” is to misunderstand—quite egregiously—the ethical limits of  parental authority.

A more reasonable conclusion than the AAP’s, then, is that the person whose penis it is should be allowed to consider, for himself, the available evidence (in all its chaotic murkiness) when he is mentally competent to do so—and make a personal decision about what is, after all, a functional bit of his own sexual anatomy and one enjoyed without issue by the vast majority of the world’s males.

Health benefits and medical ethics

According to the Seattle-based physicians group Doctors Opposing Circumcision, there is neither a medical nor an ethical case for removing healthy genital tissue from baby boys. They can’t consent to the procedure in the first place, and the bulk of the claimed—yet heavily disputed—health benefits don’t actually apply to them: babies are not sexually active, yet circumcision is supposed to protect chiefly against sexually-transmitted infections and related diseases. In any case, these are afflictions whose prevention is much more soundly assured by the use of a condom (and other safe sex practices) in adulthood than by genital surgery in infancy. With respect to the issue of urinary tract infections in early childhood, remember that these are rare for boys (about 1%), and can be easily treated with antibiotics if and when they do occur—no surgery required. A recent Cochrane Review—the highest standard of medical analysis—found no reliable evidence that circumcision does in fact protect against UTIs, and even studies that do find a link report that 111 circumcisions would have to be performed to prevent a single case of UTI.

So how did the AAP reach its much-hyped, yet ultimately fallacious, and as I will argue, ethically unjustified conclusion?

* * *

First, let us be clear about what their position is. “This is not really pro-circumcision,” explains one of the authors of the technical report behind the new analysis. You wouldn’t know that from reading the week’s headlines, which have taken the “health benefits” narrative and gone running impetuously on to town, but there it is from the horse’s mouth. Instead, the AAP believes that the purported benefits of circumcision are merely “sufficient” to “justify access to this procedure for families choosing it” and to “warrant third-party payment for circumcision of male newborns” if and when it does occur.

Here they depart from their 1999 statement in asserting that (1) the benefits of the surgery definitively outweigh the risks and costs and (2) that it is therefore justifiable to perform the operation without the informed consent of the patient. This does not follow. Just as with the parental “proxy” rule discussed above, in medical ethics, the risk/benefit rule was devised for therapeutic procedures aimed at treating an extant pathological condition, and for minor prophylactic interventions such as vaccination (interventions that, notably, most rational adults would choose for themselves, and that are rarely or never a source of later resentment). It has no relevance to nonessential amputative surgery, especially when it involves the removal of healthy, functional erogenous tissue from the genitals, and when (once again) safer, more effective substitute strategies exist for achieving the same ends.

One might be surprised to learn that the word “condom” does not appear even once in the 28 page AAP report.

In making their risk/benefit calculations, then, the AAP simply leaves out a critical bulk of factors relevant to the equation, including the existence of a range of proven healthcare strategies like condom-use or the administration of vaccines (including an effective HPV vaccine) and antibiotics. If they had taken the time to consider human rights and bodily integrity issues, the function of the foreskin, its value to the individual, and his possible wishes in later life, as well, their computations would arguably yield a different answer.

Some readers will be unaware that the AAP is not a dispassionate scientific research body, but rather a trade association for pediatricians. Those among its members and stakeholders who perform NTCs stand to profit from the procedure, to the collective annual tune of $1.25 billion according to one (albeit not impartial) estimate. Given the yawning potential for a financial conflict of interest, then, there needs to be a very strong, independent medical case for circumcision; and the AAP had better be able to show that it is both the safest and most cost effective means of promoting infant health. Both of these propositions fail, however, as I will continue to show in what follows. * * * The AAP has been tossing and turning on the question of circumcision since 1971, when it announced that “There are no valid medical indications for circumcision in the neonatal period.” Emphasis mine. From 1999 until August 27th of this year, the AAP had maintained that the “health benefits” of circumcision were perhaps neck-and-neck with the costs, at best, so that it could not recommend the procedure from a therapeutic perspective. This policy was in line with the still-current official position of every other major medical association in the world. Except, actually, those that now actively campaign against circumcision, such as the Royal Dutch Medical Association in Holland. For the AAP to revise its stance, then, it stands to reason that something must have changed—either human biology has altered, or some new evidence must have cropped up—to justify tipping the cost-benefit scales away from their recently prior equilibrium. Indeed, the AAP circumcision task force makes much ado of a collection of studies conducted in Africa between 2005 and 2007 purporting to show a link between circumcision and a reduced risk of becoming infected with HIV. According to the New York Times, these studies include 14 publications “that provide what the [AAP] characterizes as ‘fair’ evidence that circumcision in adulthood protects men from HIV transmission from a female partner.” Notice the phrase in adulthood. The AAP policy, by contrast, is concerned with circumcision in infancy, a procedure for which there is literally no evidence of a protective effect against HIV. Notice also “fair” rather than “good” evidence and that the findings apply exclusively to (heterosexual) (African) (adult) males. This is in contrast to females, for whom circumcision of the male partner is apparently a risk factor for becoming infected with HIV. The New York Times continues: “Three of the studies were large randomized controlled trials of the kind considered the gold standard in medicine, but they were carried out in Africa, where H.I.V. — the virus the causes AIDS — is spread primarily among heterosexuals.” There are a number of things to say about these “randomized controlled trials.” First, the trials appear to have been “controlled” in name only, as this exhaustive analysis demonstrates. Clinically relevant flaws included “problematic randomization and selection bias, inadequate blinding, lack of placebo-control … inadequate equipoise, experimenter bias, attrition … not investigating male circumcision as a vector for HIV transmission, not investigating non-sexual HIV transmission, as well as lead-time bias, supportive bias … participant expectation bias, and time-out discrepancy (restraint from sexual activity only by circumcised men).” Hence, as I explained in this earlier post, the “Africa studies” may not have been a clear-cut example of “gold standard” medical research (but see the counterarguments cited in that commentary). Critics have also pointed out that the “60%” figure that is typically offered as the relationship between circumcision and reduction of HIV infections is the output of a potentially misleading statistical sleight-of-hand: the absolute reduction between the circumcised and intact groups in these studies was just 1.3%. Whether such a reduction will have meaningful ramifications at the population level is the subject of ongoing dispute. The next thing to highlight is the part of the quote that comes after the “but” – a very important “but” – namely that “[the trials] were carried out in Africa” where, as the article goes on to explain, HIV is mainly a heterosexual phenomenon. Outside of Africa, it is mainly not—it is largely transmitted among injecting drug users and gay men, at least in the United States—which means that even if we were to accept the data from the “randomized controlled” studies, we would have very little evidence that circumcision could be useful in the country that is actually the subject of the AAP’s analysis. The same holds for countries such as Australia, and New Zealand, and indeed most anywhere else in the developed world. The epidemiological and social environments are just flatly non-analogous — as this study shows. Hence, as even the authors of the AAP report acknowledge, “the degree of benefit, or degree of impact [of circumcision], in a place like the U.S. will clearly be smaller than in a place like Africa.” Of course, we already knew that circumcision does not present a serious obstacle to heterosexual HIV-transmission in the U.S., since the U.S. has both the highest rates of infant circumcision and the highest rates of heterosexually transmitted HIV among industrialized nations. (Obviously there are innumerable confounding factors that can mediate the relationship between HIV rates and circumcision rates in different cultural contexts; the point here is that those factors play a bigger role than the percentage of excised foreskins in a country’s male population.) But let’s put all that to the side. For even if it were true that circumcision offered a partially protective effect against heterosexually-transmitted, female-to-male HIV/AIDS (in epidemiological environments with very high base rates of such transmission) or other STIs such as HPV (for which, as I stated before, there is an effective vaccine), it would still not follow that the procedure could be ethically performed on infants, much less on infants in the developed world. Given that there is a cheaper, more effective, less invasive, less coercive alternative—namely condom-use and other safe sex strategies in adulthood—it is inconsistent with biomedical ethics to endorse the risky genital cutting of a young child toward the same ostensible end. As pediatrician, statistician, and professor of clinical medicine Robert Van Howe showed in this recent cost-benefit analysis, infant circumcision is more costly and does more harm than leaving the baby alone, even based on models that start from very generous premises about the potential health benefits of foreskin-removal. If the AAP wants to justify “third party payments” it cannot plausibly claim them for a procure that is more perilous, more ethically problematic, less effective and less cost effective than available alternatives. The government dime is clearly better spent elsewhere. So let’s review: 1. The AAP used to say that circumcision could not be recommended on health grounds, which was, and as I have argued, remains, the only scientifically and ethically credible position for it to maintain. 2. In 2012, the AAP revised its position (while stopping short of a recommendation) in light of “new evidence” suggesting that the health benefits could now be said to “outweigh” the harms and risks of the procedure. 3. The “new evidence” consists almost entirely of data collected in Africa between 2005 and 2007 suggesting that circumcision in adulthood, in environments suffering from an epidemic of HIV/AIDS, may reduce the risk of contracting HIV through unprotected, female-to-male, heterosexual intercourse (although it may increase the risk of HIV transmission from males to females). 4. These data, however, are of “fair” quality (according to the AAP), and show an absolute risk reduction for HIV of only 1.3% between the treatment and control groups. Yet even if these data were taken seriously on their own terms, they would only apply to adult heterosexual males in Africa – not to infants in the United States. Indeed, the AAP report itself makes essentially this same last point: “… the task force recommends additional studies to better understand the impact of male circumcision on transmission of HIV and other STIs in the United States because key studies to date have been performed in African populations with HIV burdens that are epidemiologically different from HIV in the United States.” Emphasis mine. Yes, and until those studies are run – and run properly, with consenting populations, under strict ethical controls – it would be prudent for the AAP to abstain from making unsubstantiated claims about the benefits of circumcising infants in the United States. Especially since, as they concede on page 772 of their report “the true incidence of complications after newborn circumcision is unknown.” It should go without saying that if one doesn’t know how often complications occur, then one is ill-equipped to assert that the benefits outweigh them. One wonders how they ran these calculations. * * * It took the AAP circumcision “task force” several years to choreograph its latest tap-dance routine. Why it has produced a document that is out of line with both world opinion and the most basic of bioethical principles is a fascinating—and troubling—question, but one which I cannot hope to answer in a single post. Whatever the reason, however, one can be sure that it has more to do with culture than with science. As medical historians and cultural analysts have meticulously documented, circumcision as a birth ritual remains deeply, and uniquely, embedded in American medical culture and in the naïve expectations of doctors and parents alike. This sets the U.S. apart from everywhere else in the developed world—certainly outside of religious communities for whom the ritual is still self-consciously sacramental, and by whom it is performed without needing the rationalization of “health benefits.” Like any ritual, American proponents of circumcision are loath to give it up, for dread of the unknown consequences. * * * UPDATE – as of 27 May, 2013 Since this post was first published in August of 2012, some interesting developments have come about. To begin with, two major critiques of the AAP documents were published in leading international journals, one in the Journal of Medical Ethics, and a second in the AAP’s very own PediatricsThis second critique was penned by 38 distinguished pediatricians, pediatric surgeons, urologists, medical ethicists, and heads of hospital boards and children’s health societies throughout Europe and Canada. These authors stated unequivocally: Only one of the arguments put forward by the American Academy of Pediatrics has some theoretical relevance in relation to infant male circumcision; namely, the possible protection against urinary tract infections in infant boys, which can easily be treated with antibiotics without tissue loss. The other claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts, and penile cancer, are questionable, weak, and likely to have little public health relevance in a Western context, and they do not represent compelling reasons for surgery before boys are old enough to decide for themselves. So how did the eight members of the AAP special Task Force on circumcision reach a set of conclusions that are in direct contradiction to those reached by the majority of their peers in the developed world? As I speculated in my original post, and as the title of the critique I just quoted from makes clear, one plausible explanation is that there is: “Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision.” In other words, the AAP members come from an unusually pro-circumcision culture, such that their ability to evaluate the practice dispassionately may have been at least partially compromised. Intriguingly, the AAP took the time to respond to this possibility in a formal reply, also published in Pediatrics earlier this year. Rather than thoughtfully addressing the specific charge of cultural bias, however, the AAP elected to boomerang the criticism, implying that their critics were themselves biased, only against circumcision. They write: The central claim of these authors is that the conclusions of the task force report are culturally biased, leading the task force to a flawed understanding of what constitutes trustworthy evidence and to conclusions that are far from those reached by physicians in most other Western countries. The “obvious” cultural bias to which they refer apparently has its genesis in “the normality of non-therapeutic male circumcision in the US.” All of the commentary authors hail from Europe, where the vast majority of men are uncircumcised and the cultural norm clearly favors the uncircumcised penis. In contrast, approximately half of US males are circumcised, and half are not. Although that heterogeneity may lead to a more tolerant view toward circumcision in the United States than in Europe, the cultural “bias” in the United States is much more likely to be a neutral one than that found in Europe, where there is a clear bias against circumcision. Let me take this one step at a time. First, the AAP states that “All of the commentary authors hail from Europe.” This is not true. Indeed, this factual error is emblematic of the committee’s lack of attention to detail as displayed in their earlier reports. Instead, the distinguished Canadian pediatrician Noni McDonald, the first woman to become a dean of medicine in Canada, was one of the authors of the commentary in question, and Canada is not in Europe. But perhaps the AAP was close enough. The other 37 authors do indeed hail from various European countries including several from England. Notice, too, the AAP’s use of the term “uncircumcised penis” — as though it were a penis just waiting to be circumcised. They might also have called it an “intact”, “whole,” or “normal” penis, but their pro-surgery bias colors even their basic terminology. For a comparison, we would not ordinarily refer to a woman’s breasts as “un-mastectomized” in a report about breast cancer. The AAP’s point about Europe, of course, is that it is a land “where the vast majority of men are uncircumcised and the cultural norm clearly favors the uncircumcised penis.” Perhaps the AAP would like us to believe, then, that it’s really just one regional cultural norm versus another. But in fact the vast majority of cultures worldwide happen to ‘favor’ the ‘uncircumcised’ penis (and indeed most living men possess one), as it is the default, healthy condition for male human beings as well as other animals. By contrast, non-therapeutic genital surgery performed on children is non-normative globally. In the case of female children, it is almost universally condemned. (I am not arguing, of course, that mere global popularity is evidence in itself for the greater soundness of the dominant norm. There are a number of other reasons to favor the mis-identified “European” perspective, as I will explain in a moment.) The AAP then states, “In contrast, approximately half of US males are circumcised, and half are not.” But note that this is a recent development. Rates in the US were as high as 80 percent in the late 1980s, and even higher in the 1960s when routine circumcision was at its peak. Note, too, that a recently-achieved 50% circumcision rate does not entail that the American norm regarding circumcision is only 50% favorable. Instead, attitudes toward circumcision in the US remain overwhelmingly positive, and uncircumcised men are frequently subjected to ridicule as well as to ignorant accusations of being “less clean.” Furthermore, assuming pre-1980 dates-of-birth, and given the very high base rate of circumcision from that earlier period, it is more than likely that 100% of the male Task Force members are, themselves, circumcised. In addition, both the Chair of the committee, Dr. Susan Blank, and one of its members, Dr. Andrew Freedman, have a documented religio-cultural bias in favor of circumcision on top of any baseline “American” one: Dr. Freedman has admitted to ritually circumcising his own son on his parents’ kitchen table. Not only is this in violation of the AAP’s own code of bioethics prohibiting physicians from conducting surgery on family members (let alone in non-sterile environments), it also provides additional evidence of a pro-circumcision bias among the AAP Task Force members. What does the AAP mean to demonstrate, then, with its reference to the 50% circumcision rate among American males post 1990? That they are “neutral” on the issue? Given that (evidently) not one of the American males actually sitting on the AAP circumcision committee has an intact penis, this citation is somewhat misleading. The strength of the “50/50″ defense is further diluted by the fact that fully 25% of the committee’s members, including its Chair, have reasons to support circumcision that are quite independent from any medical considerations. As Freedman stated in a recent interview, “I [circumcised my son] for religious, not medical reasons. I did it because I had 3,000 years of ancestors looking over my shoulder.” This is not even to raise the specter of the committee’s bioethicist, Dr. Douglas Diekema. Diekema, too, gives a dangerously wide leeway for parental cultural motivations when it comes to healthcare decisions that may be harmful to children or that may violate children’s rights. Most notably, he has “testified on behalf of parents convicted of child neglect who failed, on religious grounds, to seek medical care for their seriously ill child.” He has also written in favor of certain forms of female circumcision, such as nicking girls’ clitorises with a razor if requested by their parents. To imply, then, that the AAP committee was simply evaluating the evidence regarding circumcision from a “neutral” or “50/50″ position of normative equipoise is not only misleading, it is literally unbelievable. But let us go along with the AAP and consider their argument a bit more. Let us even concede that the mainly European authors of the “Cultural Bias” commentary are, themselves, biased—only against circumcision rather than for it. Well … of course they are! Being biased against unnecessary surgeries performed on nonconsenting patients should be the default position of any healthcare professional worthy of the title. Such a position follows naturally from the principles of biomedical ethics that doctors become obliged to uphold upon receiving their medical degrees. The doctors’ country of origin should be of no consequence. Let me summarize. By suggesting that a cultural norm favoring the non-therapeutic, non-consensual surgical modification of a child’s penis is somehow on par with, or just as reasonable as, a medical-ethical norm favoring the avoidance of such surgery unless it is absolutely required, the AAP committee simply reveals its cultural hand. The “European” commentators, by contrast: “have ‘a clear bias against circumcision’ the same way they have a clear bias against parentally-elective infant toe amputation.” They should be biased against needless surgical risk, especially when the patient cannot consent. They don’t even need a special “Task Force on Leaving Boys’ Genitals Alone” to prove it. I will close with an honest suggestion. Perhaps the next time the AAP convenes a committee to consider the prudence of cutting off people’s foreskins, they should think about appointing at least one member who actually has one. ____________________________________________________ See Brian’s most recent previous post by clicking here. See all of Brian’s previous posts by clicking here. Follow Brian on Twitter by clicking here. #### 128 Responses to The AAP report on circumcision: Bad science + bad ethics = bad medicine • Robert Darby says: What strikes me about the AAP’s new policy is how embarrassingly out of date it is. The rest of the developed world has moved on from a debate as to the future health benefits of non-therapeutic circumcision of infants and are now arguing over its legal and ethical status. The AAP policy is really responding to an old question “Should NTC of infants be compulsory?”, and Dr Diekema – the principal author of and spokesman for the policy – thinks he is being very reasonable, fair-minded and ethically aware to give a hesitant “Not really – parents are allowed to choose”. In other parts of the world, thoughtful people are asking a different question: “Is NTC of minors legally and ethically permissible”, to which the considered response is “Probably not.” In Germany an appeal court has decided that circumcision constitutes bodily harm and is unlawful (1), and in Australia a law reform institute has recommended that the practice be strictly regulated and legally prohibited in most instances (2). In a real sense, the AAP policy is a reply to international advances in human rights law and bioethics that have already determined that NTC of minors is unacceptable in civilized societies that respect the individual. To ignore these developments is a sign of the same ostrich-headed provincialism that has stopped the United States from ratifying the UN Convention on the Rights of the Child. I would strongly endorse Brian’s point that the policy’s conclusions and recommendations are illogical. It is perfectly obvious that the “health benefits” of NTC are highly controversial and that – on a world scale, and even within the United States – there is no consensus on the issue. It is misleading and verging on dishonesty for the policy to imply that some sort of consensus or end to the debate has been reached. It is thus quite illogical for it to recommend that parents should decide about whether a boy should be deprived of his foreskin. In a situation of medical controversy and doubt, the logical recommendation is that the owner of the of the foreskin should be the one to decide whether he is convinced by the health arguments, or whether he is willing to take his chances. In its own policy statement (Law and ethics of male circumcision), the British Medical Association puts the issue far more acceptably: “There is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure. At present, the medical literature on the health, including sexual health, implications of circumcision is contradictory, and often subject to claims of bias in research. … Doctors should ensure that any parents seeking circumcision for their son in the belief that it confers health benefits are fully informed of the lack of consensus amongst the profession over such benefits, and how great any potential benefits and harms are. The BMA considers that the evidence concerning health benefit from non-therapeutic circumcision is insufficient for this alone to be a justification for doing it.” (1) One wonders whether Diekema places the faith of parents above the health of their children. He was, after all, a supporter of the AAP’s short-lived policy on female genital mutilation issued in 2010, endorsing “mild” forms of female circumcision, as a mark of respect for the cultures that traditionally perform such rituals (1). And not only that: in 2010 a boy’s parents were charged with manslaughter after their son died from a urinary tract blockage; they had refused to seek medical treatment for him and insisted on relying on faith healing. At their trial Dr Diekema appeared for the parents as a defence witness. (2) • Somegirl72 says: Great post! Well said. • TD Smith says: “In a situation of medical controversy and doubt, the logical recommendation is that the owner of the of the foreskin should be the one to decide whether he is convinced by the health arguments, or whether he is willing to take his chances.” This presumes that the “owner” (Is ownership really the appropriate concept for this? Is foreskin property?) of the foreskin has the capacity to make decisions. This is exactly the crux of the issue of infant circumcision. Given that we generally don’t accept the notion that infants have this ability, who then can decide? You seem to claim that this decision can’t or shouldn’t be made by parents. Why? Generalized human rights can’t be the answer, because you yourself have expressed support for the need for a Convention on the Rights of the Child, which presumes that the rights of the child are, in some significant way(s), different than other human rights; to put it another way, that children are not (yet) fully human. I’m not saying children don’t have the right to bodily integrity; they do. I am saying that this right, like others, might need to be qualified when balanced against the rights of others, namely that of parents to direct the course of their children’s upbringing. It seems to me that if you want to change the status quo of parents being the final arbiters of this decision for their infants, and unilaterally make the decision for them that they can’t circumcise their children, that you need to make a much more comprehensive and compelling case for the harms of circumcision than can yet be supported by the controversial research and lack of consensus on the issue. This is the right debate. As Brian notes, several medical associations around the world are working towards doing just that, but please don’t act as though that debate is over, or even that an outcome prohibiting circumcision is inevitable. That does a disservice to your position. • Circesadreim says: “I am saying that this right, like others, might need to be qualified when balanced against the rights of others, namely that of parents to direct the course of their children’s upbringing.” Why? We would never apply that same sort of thinking – i.e., the need for ‘balance’ or the ‘rights of others’ – to the body of a little girl. • TD Smith says: You ask why any right would ever need to be balanced against another? Because that’s the nature of ethics when rights collide. That’s a major function of the legal system. You’re right that we don’t view male and female genital cutting similarly. That’s in part because the genital functions differ, and much more because the practices exist in completely dissimilar social contexts. You can’t remove the act from its social context. And yes, parents do have some right direct their children’s upbringing. This is standard. Whether or not that right includes the right to circumcise infant boys is, for the moment at least, an open question, and I welcome this discussion on that question. For a slightly more detailed account, please see my response to Brian’s earlier post, here: http://blog.practicalethics.ox.ac.uk/2012/07/replying-to-a-critic-my-last-circumcision-post-for-a-while-with-video-debate/ • Hugh7 says: “Is foreskin property?” It sure is when they sell it. • Hugh7 says: “Given that we generally don’t accept the notion that infants have this ability, who then can decide? You seem to claim that this decision can’t or shouldn’t be made by parents.” You seem to assume that a decision has to be made. It doesn’t. Having a foreskin is not a diagnosis. Cutting it off is not a treatment. In most of the developed world parents are not offered this “decision” and they don’t miss it. It exists only in a culture in which circumcision has become a norm. While it became a majority practice in Australia and New Zealand in the 1950s, it never became a cultural norm (and is now done to fewer than one in 8 Australians, one in 20 New Zealanders – mainly Polynesians of Pacific Island origin for cultural reasons). One reason for the differnce may be that it was already on its way out before the sexual revolution brought on by oral contraception, when sexual matters were not discussed. • Michelle says: To me this whole issue of having to justify why it is unacceptable (or acceptable) to cut off normal body parts and to argue endlessly about “benefits and risks” is absurd when we don’t do this to justify not cutting off (or cutting off) any other normal body parts. We don’t do studies of the risks of cutting, or not cutting, off any other body parts. It should be self-evident that circumcision is flat out wrong. What is the matter with people that they can’t see this? DUH??!!! The harms of circumcision are well-known to many people. The long-term effects are not so well-studied, but other traumas are fairly well-researched and are surely comparable in effect to circumcision. We have decided that shaking our kids or hitting them, etc is wrong. We have decided that female circumcision is wrong-the AAP calls it mutilation, then says it is nothing like male circumcision. Flat out lies. I had no cultural blinders about this, and I figured out real quick that it violated my ethics. • TD Smith says: “It should be self-evident that circumcision is flat out wrong.” That’s just it, Michelle. It isn’t self evident. Not to the AAP. Not to the millions of parents all around the world that choose to circumcise their children. And, for what little it’s worth, not to me either. I appreciate your point of view that circumcision is wrong in an absolutely sense. From that point of view, it seems like it SHOULD be self-evident, but there are other people with other points of view. Doesn’t it strike you as, at the least, a bit presumptuous to assert the absolute correctness of your point of view over everyone else’s on the strength of little more than a feeling that this practice is “self-evidently” wrong? Obviously society has to draw lines somewhere; we can’t simply accept everyone’s point of view, because that would lead society into a relativist abyss. But similarly, for you to assert your sense of right and wrong on others, many of whom feel a deep connection to the tradition of circumcision, requires compelling reasoning. I applaud the efforts of circumcision opponents who are doing the hard work of building this reasoning in a formal way and engaging with people in good faith attempts to change minds rather than assert their point of view over others. • Michelle says: I have more than just feelings to back up by “absolute correctness”point of view. Have you ever performed circumcisions? Well, I have. Have you seen the pain and heard the screaming and watched the babies fight the restraints and exhaust themselves crying? Well, I have. And yes, I do believe I am absolutely correct about this issue. Do I have an understanding of where others who support circumcision are coming from? Of course I do. I work with them daily. It is very easy to get sucked into the mindset in this country and in the medical field that circumcision isn’t anything bad-it’s just a normal part of life here. It is so easy to become like Mengele and think that it is OK because parents ask for it and nurses promote it and physicians perform it and life goes on. So easy to inflict harm on others. But it goes much deeper than all that. It ate away at my soul and my inner voice kept speaking up to say, “This is wrong. You are harming this child. Why are you doing this to someone else’s body? Can’t you see he doesn’t want this done? Would you do this to your child?” Would I want to be forcibly strapped down and have portions of my genitals, or any other body part, forcibly cut off without adequate anesthetic? Absolutely not. Did I have my children circumcised? Absolutely not. Do I understand that others don’t see it my way? Of course I do. Do I have a right to vent my frustration about people who spout off “facts and assumptions” supporting circumcision without any evidence to back them up? Yes. Do I know the medical literature in detail on this topic? Yes. Have I published on this topic? Yes. Male and female genitals are derived embryologically from the same tissue. The reasons given for female circumcision are basically identical to the reasons given in our culture for male circumcision. It is absolutely wrong either way. • TD Smith says: “It should be self-evident that circumcision is flat out wrong.” That’s just it, Michelle. It isn’t self evident. Not to the AAP. Not to the millions of parents all around the world that choose to circumcise their children. And, for what little it’s worth, not to me either. I appreciate your point of view that circumcision is wrong in an absolutely sense. From that point of view, it seems like it SHOULD be self-evident, but there are other people with other points of view. Doesn’t it strike you as, at the least, a bit presumptuous to assert the absolute correctness of your point of view over everyone else’s on the strength of little more than a feeling that this practice is “self-evidently” wrong? Your ethics aren’t universal, and not everyone shares them. For your to assert them as absolute is, itself, unethical. Obviously society has to draw lines somewhere; we can’t simply accept everyone’s point of view, because that would lead society into a relativist abyss. But similarly, for you to assert your sense of right and wrong on others, many of whom feel a deep connection to the tradition of circumcision, requires compelling reasoning. I applaud the efforts of circumcision opponents who are doing the hard work of building this reasoning in a formal way and engaging with people in good faith attempts to change minds rather than assert their point of view over others. • Petit Poulet says: Does someone have to demonstrate that murder is wrong? Does someone have to demonstrate that rape is wrong? Does someone have to demonstrate that genocide is wrong? Circumcision of an infant is a violation of the their right to bodily integrity and security of person. The only question is whether an infant is a person with human rights or chattel who can be used instrumentally as parents or the community pleases. The path down cultural realism can make anything permissible. • Michelle says: Circumcision is instinctively wrong. But many do not listen to their inner voice; they build walls and defenses that disallow any introspection. Our society is detached from the soul and spirit in many ways. • Petit Poulet says: Parental rights are a dead dogma. They serve no purpose. Parents do not have the “right” to direct the course of a child’s upbringing. They are allowed the opportunity or privilege to do so. This can be taken away at any time. No one has a “right” to control the life of someone else. That would be slavery the controlled person would become chattel. A better way to think of this is that the parents have a duty to protect the child’s rights because the child does not have the power to do so. According to John Rawls, a basic right, such as the right to bodily integrity, can only be violated if doing so shores up another basic right. He would not include the parents right to religious practice (as opposed to religious belief) as a basic human right. • Judith says: Dang, I never thought of it that way, but you’re right! If parents think they have the “right” to abuse their child, the CPS can take that child away from them. So they didn’t have the right to do anything, only the ignorant assumption they could do what they wanted. A duty to protect is way better, and parents who circumcise their baby boys are definitely failing in that basic and important duty! WELL SAID!! • Alexandro Gradilla says: Bravo Robert!!! I am a big fan of your work! • Maria Bangs says: Great article, Brian. I find myself continually bothered by the AAP’s acknowledgement of not knowing true risks and complication, yet no call to action to address or study true incidence of risk. It would seem logical & ethical to commission a study on actual risk before touting flimsy “benefits” as outweighing these not yet determined risks. • Michelle says: It would actually be a violation of research ethics to do “experiments” on infants and follow them over time to determine risks. You can’t do research on people who can’t give consent. Period. • Peter English says: if you can’t experiment on those who can’t consent, you’ll never have better, safer, more effective treatments for children, people with dementia, and others. • Hugh7 says: Books have been written about this. There are ways around it (like testing on animals or in vitro first, to ensure no harm – and yes, thalidomide – then giving the best known treatment to both groups, and the experimental treatment as well to the experimental group). But infant circumcision is not like real treatments. It’s prophylactic surgery reducing healthy, normal, functional tissue. It became customary to prevent/cure non-diseases like “masturbatory insanity”, and it’s been searching for a justification ever since. The whole focus on circumcision is misguided. • Michelle says: I am talking about experiments on children that involves removal of normal tissue, not treating a disease. If a disease was present, then the parents or guardian can give consent. In the absence of disease, there is no basis for experimentation. Forcing someone to go through an unnecessary surgery, such as what happened to Jews during the Holocaust, is unethical and violates the Helsinki declaration. • Petit Poulet says: Great summary. How can they say the benefits outweigh the risks when they admit they don’t know what risks are. To make that claim they need to provide numbers and do the math. They do neither. Others have done the math for them (even the godfather of the circumcision lobby, Edgar Schoen) and found their numbers will not give the results the Task Force wanted, so the Task Force ignores them. I don’t know how this will play out with membership of the AAP, who are much less likely to circumcise their sons than the populations they care for. Will they be insulted by the Task Force’s denigration of males who have a complete penis, who happen to be their sons. Will they ignore it based on their experience with their family members that the foreskin is not birth defect and rarely has problems? Will they send in complaints to the AAP? Pediatricians are pretty easygoing professionals. They have learned to go with the flow and be flexible because they deal with children and parents of all ages and life situations. Their national meeting is in New Orleans October 20 – 23. The AAP needs to be told they made a huge mistake. The AAP membership needs to let the AAP know that when pontificating on human genitals they are now zero for two. • Petrina Fadel says: Thanks forthe common sense and sound reasoning, which was lacking in the new AAP report. There was one other thing that the AAP failed to mention for preventing STDs and HIV, besides condoms that you mention. The AAP also said nothing about abstinence before marriage and fidelity within marriage (chastity) as a means of preventing sexually transmitted diseases. Behavior can also prevent these diseases, without the losses associated with circumcision. You can read my analysis of the AAP Statement at http://www.drmomma.org/2012/08/aap-circumcision-policy-statement.html I hope you will send your analysis to the AAP Board of Directors. They need to read it. Email addresses are provided after my analysis. • roger desmoulins says: Petrina, you are entirely correct. If people abstain from fornication and adultery, 99% of the claimed “health” reasons for routine circ go down the drain. Are we to look at a newborn boy and think to ourselves “he could turn into a condom-free horndog after he turns 16, and catch and spread who knows what diseases. Let’s alter his penis now, for his good and of the women he fornicates with.” One should never prejudge the morals of a new human being in that fashion. When I argued, as I have here, to a prominent advocate of RIC, his reply was “roger, what planet do you live on?” If one alters the penis to reduce the wages of sin, the outcome will be more sinning. • Brian D. Earp says: Dear Roger, It’s true that safe sex practices–including condom use, and thoughtfulness in one’s choice of partners–are required to prevent the transmission of sexually transmitted diseases. This is true whether a person is circumcised or uncircumcised. But the moral-medical framework you offer here — according to which sex between unmarried persons is “sinful” and that circumcision would allow people to engage in such sinful activities without reaping the consequence–is, I think, deeply problematic. I won’t bother with the “sin” argument, because it stems from a religious metaphysic I don’t find at all plausible–don’t share with you–and hence I wouldn’t be very convincing. But the latter part — the medical part — I must call you out on. It as not at all clear that circumcision does, in fact, reduce a person’s chances of contracting sexually transmitted infections, and it’s even less clear that it does so to any significant degree. There is also quite a bit of evidence linking circumcision to INCREASED transmission of STDs, as I explained in my analysis. In Africa, there is a serious problem by which circumcised men think they have been “vaccinated” against HIV/AIDS, so they fail to wear condoms — with their spouses or whomever they are having sex with — thereby exposing themselves to the virus. I repeat: circumcision or no circumcision, condoms must be worn to effectively stop the spread of sexually transmitted infections. The “wages of sin” are NOT meaningfully reduced by circumcision. Yours, Brian • Michelle says: Great article and great comment. It seems the AAP, and America in general. thinks that STD’s are running rampant when in fact most people have never had an STD. That we could all have so much fun! Just kidding. It also implies that males are somehow completely depraved and unable to control their sexual instincts unless circumcised. The inferences are completely outlandish and insulting to intact males, and all of us really. Circumcision actually alters sexual behavior by increasing deviant sexual preferences (Laumann) and circumcised males have more partners. So, circumcision will actually increase STD’s, HIV, HPV (which is rampant in my circumcised population anyway.) The intact males I have known and raised have greater respect for women and are more sensitive and caring overall. • Jere DeBacker says: Great Article and Comments. I am still struck with the tap dance around the religious bias from which the new AAP “statement” is born. Is anyone going to mention that the self appointed committee that wrote this statement is headed by a Jewish woman. How many of the other committee members are Jewish? In Colorado, we just went through a horrendous fight with the State Legislature. A Jewish woman Senator (wife of a Rabbi) and an Hispanic woman M.D. (general practice) Senator sponsored a bill to restore Medicaid funding for neonatal circumcision for cultural and “medical” reasons. Their argument was practically word for word the same as the new AAP statement. In some of the public and private discussions, we were told that the Jews are terribly afraid that circumcision will be banned and they will not be able to practice their ritual. Both of these women spoke of circumcision as some kind of a gift that was bestowed on lucky baby boys and that it was cruel to leave poor boys out in the cold, when their parents couldn’t afford to have them cut like real Americans. Thankfully we won, because Republicans didn’t want to pay and gay men (Democrat) legislators knew better. The new articles, blogs and official statements that have come from the AAP “statement” are a wonderful and concise rebuttal to all these claims. But, I’d love to see more discussion about the fact that circumcision is not and has never been medical. It is simply a cultural practice done by the medical community that seeks and has always sought medical justification. I feel that it needs to be stressed that all the “studies” which report benefits of circumcision are created and administered by known circumcision advocates. (and circumfetishists) Much more needs to be written to discredit Wiswell and his outrageous “studies”. Can someone start a Change.Org petition against the AAP? Can some of the groups with credentials file complaints against the committee members with their respective medical Boards to investigate their gross misconduct in this whole debacle? Thanks for your work. Thanks for listening. Thanks for your consideration. Sincerely, Jere DeBacker, Denver, CO • TD Smith says: Hi Brian, As always, your diligence, thoughtfulness, and fair-minded evidence-based approach are much appreciated. You do yourself and the practice of civil discourse a great credit. Great analysis of the AAP position change, and perhaps more fundamentally, of the nature and structure of the AAC itself. Also fascinating to learn that male circumcision, while potentially lowering the incidence of male-contracted HIV, increases the incidence of female-contracted HIV. That said, I feel compelled to say that the post you link from DRMOMMA (http://www.drmomma.org/2009/09/functions-of-foreskin-purposes-of.html) about the functionality of the prepuce is not a good resource. While I think it does have some decent points, it’s poorly argued, very ideological, and (in my opinion) beneath you and the level of debate that you’ve set for yourself here in the blog. While it may not be appropriate to go into an exegesis of another blog post here on yours, but in the interest of substantiating my grievance, here’s a brief rundown on why I disapprove of the post. The author (not immediately apparent, labeled only as “JK”) obscure and prejudice much that it claims to educate about. While the post pays lip service to penile variation among men, noting that all penises are unique, it makes sweeping generalizations about both the functioning of the foreskin, and, more troublingly, goes on to make extreme normative and value judgments about it. The post makes unsubstantiated claims of perfection: “Babies are born perfect.” I thought it was a pretty widely accepted ethical and cultural precept that no one is perfect. Error is innate to our humanity. The post makes several appeals to ‘nature,’ which we both know to be a deeply socially constructed concept. “In nature there is no surplus, only economy. Everything provided is required.” This is not science, medicine, or education. It’s ideology. It’s a worldview that, while not completely devoid of evidence or usefulness, is not substantiated or reasoned within its own context. The post uses non-sequitur to insert prejudicial conclusions into premises, covering these conclusions with poorly contextualized medical jargon: “What we can say with certainty is that your baby’s penis will develop and mature according to his own unique genetic coding. Thus, the amount of foreskin he is born with is exactly the amount he will need for his penis to develop properly and experience comfortable, pleasurable erections throughout life.” How does a conclusion about the perfection of the amount of any given child’s foreskin follow from the premises. There are many normal biological variations in bodies that people perceive as imperfect for any number of reasons. How can the author make any claim to the perfection or imperfection of my prepuce, or any other man’s? And the post makes claims about how foreskins operate that are downright contradictory to the experience of many men, myself included. Despite the author’s lengthy discursis on the foreskin’s self-cleansing, immunological, and antibacterial functions, not only are several of the immunological and anti-bacterial functions of a healthy penis more properly assigned to structures other than the prepuce, her conclusion that “The common view of the penis or the foreskin as ‘dirty’ is unscientific and irrational.” and that “Therefore, you never need to worry about the foreskin being ‘unclean,’” are simply contradicted by several people’s experience. Anecdotal evidence notwithstanding, (alert: personal and potentially graphic details follow) I can personally attest to having suffered minor infections of my prepuce as a result of unsatisfactory cleaning during my childhood. I can assure you that my urination and natural secretion have not proved a perfect defense against the variety of pathogens in my environment, contrary to the author’s claims. The author is even wrong about the essential position of a “natural” and intact foreskin on the penis. I am uncircumcised and to the best of my knowledge healthy, and yet my prepuce does not, by itself, cover my glans, whether the penis is erect or not. It hasn’t since I was boy. In fact, I remember being confused, irritated (physically moreso than emotionally), and concerned both about whether I was normal and whether there was something biologically wrong with me when this changed occurred. Given the wealth of other wonderful and credible resources you cite in this post, I don’t think you’d be losing much to chuck the DRMOMMA link or find a slightly less biased source about the function of the foreskin. On an different note, following my response to one of your previous posts, I urge you to moderate your rhetoric about “patient consent” as it applies to infant circumcision. When you approach this particular procedure, I feel that both you and other circumcision opponents too casually dismiss more general ethical and legal principles of parent/child relationships and parental custodianship. Perhaps you disagree with current prevailing notions of parental custody and custodial consent? It’s hard to say, since you don’t make the claim that parents shouldn’t be allowed to consent to other medical procedures on their infants’ behalves. Your arguments to “patient consent” and “personal autonomy” would seem to conflict with the idea that parents have significant custody or stewardship of their children’s lives before maturity, but your failure to address that issue directly seems tacitly to approve of the idea that parents can consent to medical procedures for their children, JUST NOT THIS ONE. That is a very reasonably and defensible position, but if it’s yours, I urge you to make it more thoughtfully and explicitly than I have currently seen or to moderate your language about infants’ lack of ability to consent to their circumcisions. Once again, I thank you, Brian, for your passion, your erudition, and the diversity of opinion you feature on this site. Please continue to exercise your typical good judgment as you compile your bibliography and build your body of work on this topic. • Heather says: TD – I can’t presume to know the entirety of your childhood history, of course, but will you permit me to make a hypothesis? Many of the problems that occur among intact males, for instance with frequency of infections, are not in fact due simply to their status as intact. Rather, they are a result of an intact penis being improperly cared for when they were very young. I’m referring specifically to ‘forced retraction’ — the belief that an intact baby’s foreskin must be pulled back every so often to ‘help’ it detach from the glans and retract. It is also often believed that this is necessary in order to clean underneath. This forced retraction in fact damages the foreskin and glans, and in many ways reduces or even eliminates the protective factors that the intact foreskin is supposed to confer. Boys who are not forcefully retracted, but instead merely “clean what they see” and allow the foreskin to detach and retract naturally (which usually happens anytime between age 3 and early puberty) almost never suffer from foreskin-related problems. The culture in the US has been pro-circumcision for many generations now, therefore many parents do not know how to care for an intact penis simply because they’ve never done so before. In addition, many doctors are giving their patients false information. When my own son was born 14 years ago, my doctor told me to retract at every diaper change — and we are in Canada, where circumcision is really quite rare! Fortunately I knew better than to listen to this advice, but many parents simply have not had this information. There are numerous, numerous stories of doctors retracting boys’ penises themselves at well-baby checkups. As well as many stories of doctors telling parents that their 3-year-old boys have phimosis and need corrective surgery because they’ve not yet retracted — ignorant of the fact that this is biologically normal. It almost makes you wonder if the bad advice from doctors is deliberate — much like the song and dance of the AAP’s new statement — in order to provide these stories of problems with intact boys. I hesitate to believe that it is deliberate, but the alternate possibility — that our doctors whom we trust with our help are utterly ignorant — is not much more appealing. So once again, I cannot obviously know what happened when you and your penis were young, but I would suggest the possibility that your parents — well-intentioned and probably told to do so by their doctors — engaged in early forcible retraction, and that this is in large part responsible for the problems you had. • Heather says: “our doctors whom we trust with our help” — should read “health”. Apologies. • Circesadreim says: “When you approach this particular procedure, I feel that both you and other circumcision opponents too casually dismiss more general ethical and legal principles of parent/child relationships and parental custodianship. ” Again, we would never apply that same sort of thinking to the body of a little girl. Why is it somehow different for boys? They’re less deserving of the right to bodily integrity? • Brian D. Earp says: Hey TD — thank you, as always, for your well-considered thoughts — and I promise I will reply at length to your earlier commentary as soon as I can come up for air … First point is: I’ll find a better link for function of the foreskin. Your criticism is fair — I threw this thing together as quickly as I could to try to stem the tide of media hyperbole, and I’m sure there are a few places where I could track down a sturdier citation or illustration of whatever point I was making. Thanks for bringing this up. On the question of parent consent …. parents can give surrogate consent for needed medical procedures of course — of course they can! — but my article is about non-therapeutic circumcision, namely circumcision performed in the absence of any known pathology, on the off chance that it might do some good more than a decade later, if you discount the various risks and known costs, i.e., the pain of the surgery, the loss of functional tissue, etc. If a kid has a rotting leg or something, the parent can consent to amputation if there’s a clear medical indication and it’ll save the life or health of the child. I don’t believe that parents can morally consent to amputative surgery of the genitals for the sake of “guiding their child’s upbringing” … certainly they can’t slice off their daughter’s labia for cultural reasons (and even if some “health benefits” could be drummed up, we rightly wouldn’t stand for it) and neither should it tolerated for them to cut off a part of their sons. To overrule the bodily integrity case, there would have to be profound medical benefits, and a public health crisis — but neither is the case. Anyway — again, very grateful for your thoughts and for pushing on my claims to keep me thinking and honest. A pleasure to be in conversation with you. — Yours, Brian • Martin says: Brian, this was an excellent summary of the shortcomings and strange features of the latest AAP pronouncement on infant circumcision. It’s curious that the AAP has never convened a task force and prepared an equally extensive report on the anatomy and functions of the infant/child prepuce and how to keep it healthy right up to adulthood. Regarding parental medical proxy, it seems reasonable to distinguish on the basis of a valid medical diagnosis. Where there is no diagnosis to address an imminent condition such as disease, injury or deformity, an entirely different decision-making process normally applies (except, apparently, in the case of circumcision). This requires both physician and custodian(s) to evaluate whether this procedure or surgery can possibly be put off, whether harm to the child will occur because of or without the surgery and whether the intervention is in the best interest of the child. A common examples is otoplasty, which normally is delayed until the minor can participate in the decision. Circumcision is not de facto in the best interest of the child, and it’s also not reasonable to say that parents make this call. Circumcision is necessary or it is unnecessary; it’s a binary process at that level. To leave the decision-making about best interest in the hands of the parents would be to agree that it’s OK for some parents to believe that having a foreskin is never in the best interest of their child, healthy or not. Medicine does not agree to this level that the human penis is designed wrong. I am of the school of thought that the foreskin is functional tissue. I also believe that one of the reasons there is so much discussion about this point is that there exists wide variation in knowledge of anatomy and in human sexual response. Some men derive consistently great pleasure and feedback from using their foreskin during sex. Some men don’t, and may see the foreskin as being “in the way”, leading some to conclude that it is useless and even unsightly. And yet others start out not understanding their foreskin’s purpose or capacity for sensation, and over time this changes and they belatedly come to appreciate the design. This pattern is not limited to the foreskin; neuroanatomists have noted that for some men the nipples are “hard-wired” for pleasure in sex, some men swear that they feel nothing or even discomfort from having their nipples played with, and a third group starts out thinking that their male nipples are as useful as a bicycle to a fish and then gradually or suddenly discovering how pleasurable nipple stimulation can be. The AAP did its members and the American public a disservice with this latest statement on circumcision. The lack of acknowledgment of foreskin function, let alone any meaningful discussion of anatomy (didn’t Taylor settle this in 1996?), is inexplicable or suspicious. Combined with cherry-picked benefits and a scandalously absent honest discussion of risks and complications, the task force has managed to simultaneously promulgate and nullify their conclusions. In fact, what these last few pronouncements on circumcision seem to indicate is an internal struggle between those whose attitude is “don’t mess with the body unless there’s a problem” and those who have an agenda regarding circumcision and contrive to steer the argument their way, no matter how flimsy their case turns out to be and how awkward the final report appears. In 1989 the ideologues prevailed only in part, to their disappointment; the 1999 report was delayed 18 months from its intended release and sought a more diplomatic middle ground; and with the latest report, the proponents of circumcision have gained more ground. The problem is, their own analysis doesn’t support the conclusions, making the outcome look predetermined and the committee process appear hijacked. Given the pattern of the past 40 years, we haven’t seen the last shift in this tug-of-war. It is tragic that American boys and their families are pawns in this process, one which is less about optimal health and childhood wellbeing and more about rationalization and justification of a religious or social custom. • Lillian Cannon says: If having a foreskin were an emergent condition then there might be something to discuss. The parents would have to decide on treatment based on the information available to them at that time. However, simply having a health foreskin is not an emergency. Even as long ago as 1995, pediatricians understood that parental proxy consent is invalid for unnecessary procedures: PEDIATRICS, Volume 95 Number 2, Pages 314-317, February 1995., “Thus “proxy consent” poses serious problems for pediatric health care providers. Such providers have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses. . . the pediatrician’s responsibilities to his or her patient exist independent of parental desires or proxy consent.” In emergency conditions, such as a child diagnosed with cancer, parents may still not allow their personal beliefs to harm the child. U.S. case law holds that parents may not withhold medical treatment because of religious conviction. In any case, we need not decide the whole grand scope question of whether parents can consent to medical procedures now. Were I a judge, I would stick with a nice, narrow holding: -Seeing as the foreskin is not diseased; -And seeing as the proposed benefits of reduced STDs and infections are in dispute and can be had by less-invasive means; -And seeing as we do not know if the child will be happy with this decision when he is an adult and can understand the issues; -And seeing as prior courts have held that a parent’s religious beliefs may not supersede a child’s right to health and life; -Parents do not have the right to consent to this procedure regardless of their motivation. • Nicholas Alipaz says: Great post, I do however feel you have left out one of their key motivations, money. I only wish you had touched more on that point in your conclusions. • Petrina Fadel says: Check out all the harms resulting from circumcision in these cases- botched circumcisions, circumcision deaths, and unauthorized circumcisions. These are publicized cases of malpractive lawsuits, as well as published articles about harm. http://www.glorialemay.com/blog/?p=581 • Tom James says: The AAP report concludes MGM is beneficial enough to get money to doctors from insurance companies, while at the same time concluding that it is not beneficial enough to recommend it. Apparently the only thing the AAP really knows for sure is that its members should get money and should be protected from the possibility of being held liable for performing medically unnecessary amputations. Per their web site, the AAP actively lobbies for restrictions, limitations and caps on the liability of pediatricians who harm the children in their care. Just something to think about. • Dick-Scalper says: They brand men like a herd of cows. American men are such wimps to let their sons be subjected to this absurd surgery. If it were women tied down & cut, the Feminists would be howling all over the world. The male genitals are a cheap commodity. There is no argument too absurd for the circumcisers. They insult the appearance of the intact penis, claim that circumcision heals everything from body warts to HIV, and draw an illogical distinction between female & male genitals. Circumcision is the mark of a slave, not a free man. ~Dick-Scalper • Sylvia says: The feminists are up in arms over circumcision. Someone the other day asked why women were at the head of the intact movement. It’s because feminist mothers love their sons, are well-informed in science/health matters generally and believe in their body integrity. They are also willing and able to fight for their children’s righta. • Heather says: “I find myself continually bothered by the AAP’s acknowledgement of not knowing true risks and complication, yet no call to action to address or study true incidence of risk.” I completely agree with you. How can you claim that benefits outweigh the risks if you have no accurate way to quantify the adverse outcomes of circumcision? I have several family members who did experience circumcision complications: adhesions, hemorrhage, skin bridges, meatal stenosis, etc. to the point that some needed another surgery to correct it. How is that reported and quantified months or years after the initial procedure? Many complications are not even apparent until sexual maturity. None of this is mentioned in the report. It is completely biased in favor of circumcision, and I have little doubt that it is highly motivated by money and religion (in which order, I am not sure). It is certainly not about the health and human rights of baby boys. • Michael Keith says: I can only hope that countries like Germany continue to make this “ritual” sacrifice illegal. Only this will help in removing this scourge from humanity. Germany has attacked the problem head on. • Josc says: “I can only hope that countries like Germany continue to make this “ritual” sacrifice illegal. Only this will help in removing this scourge from humanity. Germany has attacked the problem head on.” ————————————————– Yes, I really hope so as well. But unfortunately, the religious lobby is strong and our politicans so weak. And in Germany the antisemitic “argument” is always present in cultural discussions like this. Anyway, let’s hope that Humanism and Enlightment prevails in the end. There could be a real chance if just one country finally starts. Btw, is it just a coincidence that this AAP report came out just about the time hefty discussions about circumcision rage in Germany? I dont think so… Josc, Germany • Joseph4GI says: In a news article in the Washington Post, Diekema is quoted saying: “For individuals who have decided that circumcision is wrong, no amount or quality of data will put these questions to rest…” Diekema wants to pretend like it’s all about “research” and “benefits.” Ponder this for a moment; at least ostensibly, the ethics of cutting off normal, healthy tissue from a healthy, non-consenting minor was decided on a “cost-benefit” analysis that, supposedly, erred in favor it. The unspoken and disconcerting implication seems to be that the forced genital cutting of female minors could one day be legitimized, if enough “research” and “quality data” said that it was “harmless,” even “beneficial, when performed by a trained professional member of the AAP/ACOG.” This is a textbook case of sexist special pleading; there will never be enough “quality data” that would ever justify the smallest “ritual nick,” as the AAP found out not too long ago. And yet, Douglass Diekema has the nerve to dismiss advocates of male genital integrity using a sound bite that may as well apply to himself. Projection much? • Petit Poulet says: The problem for Diekema is that most people opposing circumcision know the science better than he does. He has only read the science that agrees with his circumcision status. See Sarah Waldeck’s University of Cincinnati Law Review article on the topic. Circumcision status keeps people from being objective about this issue. • Ellen Mary says: Great! I would like to add two things: Is HIV a heterosexual phenomenon in Africa OR is illegal & quasi illegal same sex behavior poorly reported??? Also this report suggests intact boys should be forcibly retracted @ 2-4 *months*. Forced retraction @ 2-4 YEARS would be insane! Boys need not retract until as late as puberty & the advice in this report will NO DOUBT cause foreskin damage & circumcision in our twisted circumculture. It also contradicts the AAP’s published statements. No one stands a chance of preserving their son’s foreskin if forcible retraction begins in infancy. :*( • Michelle says: Check out David Gisselquist and John Potterat and Michael Fumento writings. Heterosexual HIV probably only accounts for about 1/3 of the cases: the rest are homosexual or other anal sex or primarily through injections from unsafe needles. The committee members clearly have never had any contact with a foreskin for longer than a few days. They make themselves look like idiots. I am ashamed of my country. • david garbacz says: dont forget the medical industry’s new potential cash cow product made out of foreskins. The new “spray-on skin” treatment developed by Healthpoint Biotherapeutics has been shown to stimulate new skin growth and healing of open leg wounds that occur due to poor blood circulation, according to results of a study published online Friday in the latest edition of Britain’s prestigious medical journal, T he Lancet. The treatment consists of a spray containing skin cells derived from carefully selected foreskins of newly circumcised baby boys. • Robert Firth says: “The treatment consists of a spray containing skin cells derived from carefully selected foreskins of newly circumcised baby boys” Am I just a prisoner of my own cultural biases here, or does somebody else also feel that this “treatment” is the moral equivalent of cannibalism? • I don’t think cannibalism quite fills the bill because the boys are still alive (and cannibalism can be justified for survival after natural or accidental death – the plane crash in the Andes is the classic example), but it’s certainly theft. I’ve never seen that the foreskins were “carefully selected” before. On what basis, I wonder? An ethical complication is that the cells are grown vastly, one foreskin reportedly providing football-fields worth of cells. If it had been harvested ethically there would be no problem. • Frederick Rhodes says: In the late 60’s studies were being done on PTSD from combat as the soldiers were returning home and accidently found that the simptoms of combat PTSD correlated to the simptoms of schizophrenia. Further studies revealed that PTSD from infant sexual traumas were the common factors in patience with schizophrenia and men circumcised before going to war were more likely to develop PTSD’s. This must have been what spured the AAP’s tossing and turning on the question of circumcision since 1971, when it announced that “There are no valid medical indications for circumcision in the neonatal period.” • david garbacz says: see the excellent book, circumcision, the hidden trauma. avail at amazon. i work with trauma in mental health. there is no question that there is ptsd from this practice along with attachment disorders as well. • Michelle says: I currently am a physician at a university health center and I am seeing alot of young adult males with significant anxiety and other psychological issues that seem excessive. I can’t help thinking that circumcision may be part of the issue. I also see a tremendous amount of HPV and chlamydia, urethritis even though this ‘should’ be “prevented” by circumcision, which is the norm for male students and partners of female students here. Clearly, circumcision doesn’t prevent any STD’s, HPV, etc. • Dick.Scalper says: The fix is in, they don’t give a cr@p except to keep circ going on forever. ~Dick.Scalper • Police States of America says: Circumcision is the terror-inducing tactic of the Totalitarian & his lackeys. • colombiana says: This needs to be seen/read by as many people as possible. • Anonymous says: In the study [1], Laumann et al observed that circumcised men engage in a wider variety of sexual activity than intact men, and hypothesized that this was due to the social stigma associated with being intact. The data from which that study was derived [2] does not support that conjecture: it contains no data on attitudes toward the circumcision status of the respondents. Another conjecture is that circumcised men engage in a wider variety of sexual activity because they derive less satisfaction than intact men from the smaller subset of activities engaged in by intact men and are led to engage in compensatory activities. In the examples derived from [2] below, the higher likelihood of behaviors observed in circumcised men versus intact men cannot be explained by the putative social stigma associated with being intact. Calculations were derived using the two-sample z-statistic, in this case for proportions of intact and circumcised men who reach a certain threshold of behavior out of two populations of intact and circumcised men. Likelihood of masturbating to relieve tension The first finding is a higher likelihood of masturbating to relieve tension: 47% of circumcised men masturbate to relieve tension, versus 30% for intact men. The odds ratio is (.47/.53)/(.3/.7) = .89/.43 = 2.12. The statistical significance level is 0.024.* The inter-mean distance in units of standard deviation between the distributions of the two groups is 0.43. The likelihood of avoiding sex. The second finding is that among white, non-Hispanic men at least 55 years old, 68% of circumcised men had avoided sex (recently, at some point), versus 49% for intact men who had avoided sex. The odds ratio is (.68/.32)/(.49/.51) = 2.13/.96 = 2.22. The statistical significance level is 0.047.* The inter-mean distance in units of standard deviation between the distributions of the two groups is 0.48. *The p-values are one-tailed. 1. Laumann, Edward O.; Masi, Christopher M.; Zuckerman, Ezra W., “Circumcision in the United States: Prevalence, prophylactic effects, and sexual practice.” JAMA, The Journal of the American Medical Association. Apr 2, 1997, 277, (13), 1052 – 1057. 2. Edward O. Laumann, John H. Gagnon, Robert T. Michael, and Stuart Michaels. NATIONAL HEALTH AND SOCIAL LIFE SURVEY, 1992: [UNITED STATES] [Computer file]. ICPSR version. Chicago, IL: University of Chicago and National Opinion Research Center [producer], 1995. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 1995. APPENDIX: detailed analysis First analysis: the likelihood of masturbating to relieve tension. We find that 47% of circumcised men masturbate to relieve tension, versus 30% for intact men. The odds ratio is (.47/.53)/(.3/.7) = .89/.43 = 2.12. Respondents in the Laumann study were asked if they had masturbated to relieve tension. Our null hypothesis, denoted H0, is that there is no difference in the likelihood that intact or circumcised men will masturbate to relieve tension. If H0 were true, the observations in the samples of intact and circumcised men would come from a single population of men, of whom some proportion m will masturbate to relieve tension. Accordingly, instead of estimating separately the proportion pct of circumcised men who masturbate, and the proportion pit of intact men who masturbate, the two samples will be pooled to form the pooled sample proportion m: m = (# of circed and intact men who masturbate)/(# of observations in both samples combined) Next, we calculate the two-sample z-statistic for proportions z = (pit-pct)/\sqrt{m(1-m)(1/\mathrm{circed} + 1/\mathrm{intact})} and then use the standard normal distribution to find P-values. We use the open source statistical computing package R. Here is our R session, with the Laumann National Health Social Life Survey data: > myframe <- read.spss(file=’nhsls.sps’) > attach(myframe) > intact <- myframe[GENDER==”Male” & CIRCUM==”No”] > circum <- myframe[GENDER==”Male” & CIRCUM==”Yes”] > intact_tension <- myframe[GENDER==”Male” & CIRCUM==”No” & MAST12D==”Yes”] > circum_tension <- myframe[GENDER==”Male” & CIRCUM==”Yes” & MAST12D==”Yes”] > pit <- length(intact_tension)/length(intact) > pct <- length(circum_tension)/length(circum) > pit [1] 0.3067332 > pct [1] 0.4695731 > m <-(length(intact_tension)+length(circum_tension)) /(length(intact)+length(circum)) > m [1] 0.4260985 > z <- (pit-pct)/sqrt(m*(1-m)*(1/length(circed)+1/length(intact))) > z [1] -1.985958 > pnorm(z) [1] 0.02351897 Since pnorm(z) < .05, the results are statistically significant at the 5% level. This is evidence against the null hypothesis that circumcision has no sexual effect whatsoever, and so no difference in masturbatory behavior should be detected H0: pit = pct, and in favor of the alternative hypothesis that being intact reduces the likelihood of masturbating to reduce tension Ha: pit < pct. We are led to reject the null hypothesis. Second analysis: the likelihood of avoiding sex. We find that among white, non-Hispanic men at least 55 years old, 68% of circumcised men had avoided sex (recently, at some point), versus 49% for intact men who had avoided sex. The odds ratio is (.68/.32)/(.49/.51) = 2.13/.96 = 2.22. Respondents in the Laumann study were asked if they had avoided sex–we find that this effect increases with age. We consider the case of white, non-Hispanic males age 55 or above. Our null hypothesis H0 is that there is no difference in the likelihood that intact or circumcised men will avoid sex. We show that the null hypothesis may again be rejected. We continue our session in the open source statistical package R: > circumw <- myframe[GENDER==”Male” & CIRCUM==”Yes” & ETHNIC==”White, non-hisp.” & AGE >= 55] > intactw <- myframe[GENDER==”Male” & CIRCUM==”No” & ETHNIC==”White, non-hisp.” & AGE >= 55] > intactw_avoid <- myframe[GENDER==”Male” & CIRCUM==”No” & ETHNIC==”White, non-hisp.” & AVOIDSEX==”Yes” & AGE >= 55] > circumw_avoid <- myframe[GENDER==”Male” & CIRCUM==”Yes” & ETHNIC==”White, non-hisp.” & AVOIDSEX==”Yes” & AGE >= 55] > pia <- length(intactw_avoid)/length (intactw) > pca <- length(circumw_avoid)/length(circumw) > pia [1] 0.4864865 > pca [1] 0.675 The null hypothes is$latex H_0: pia – pca = 0$. If the null hypothesis were true, the two populations would be part of the same population. Accordingly, instead of estimating separately the proportion pca of circumcised men age 55 or above who avoid sex, and the proportion pia of intact men age 55 or above who avoided sex, the two samples will be pooled to form the pooled sample proportion ma: > ma <- (length(intactw_avoid)+length(circumw_avoid))/(length(intactw)+length(circumw)) > ma [1] 0.5844156 As above, we calculate the two sample z-statistic for proportions and the corresponding P value. za <- (pia-pca)/sqrt(ma*(1-ma)*(1 /length(circumw) + 1/length(intactw))) > za [1] -1.677017 > pnorm(za) [1] 0.04676958 As in the previous example, P < .05, so at the 5% level we may reject the null hypothesis and accept the alternative hypothesis that circumcision increases the likelihood that a man age 55 or over will avoid sex. Inter-mean distance in units of standard deviations We compute the difference between the means of the distributions of intact and circumcised men. For the case of masturbating to relieve tension, we have the proportion pit of intact men who masturbate to relieve tension, and the proportion pct of circumcised men who masturbate to relieve tension. > pit [1] 0.3067332 > pct [1] 0.4695731 > qnorm(pct) – qnorm(pit) [1] 0.4287887 For the case of avoiding sex, we have the proportion pca of circumcised men who avoid sex, and the proportion pia of intact men who avoid sex. > pca [1] 0.675 > pia [1] 0.4864865 > qnorm(pca) – qnorm(pia) [1] 0.487642 The value 0.4876 applies to men of age 55 or above; a value of .4151 is obtained for white, non-Hispanic men of age 45 or above. These examples cast doubt on the hypothesis of Laumann that the wider variety of sexual behaviors observed in circumcised men is due to the social stigma of being intact. • And the whole question becomes nugatory when the rate of masturbation is by self-report. Only 47%? Only 30%? Pull the other one! • intersex says: You obviously cannot read. Kahneman writes about this kind of inability to comprehend probabilities. • Anonymous says: You foreskin worshipers love to twist things around. And you’re quite disingenuous when you keep trying to show that circumcision doesn’t reduce HIV by claiming that the US has the highest circumcision rate and the highest rate of HIV. You know full well that HIV in the US is mostly from IV drug users sharing needles and anal receptive sex. Neither of these groups of people will benefit from circumcision. However, you should note that the rate of HIV among heterosexuals in the US is quite low. And that’s probably because of the high rate of circumcision. You keep trying to claim the studies in Africa are flawed and that circumcision actually increases the rate of HIV infection. The bottom line is the major circumcision intervention in Africa is WORKING as studies show. Circumcision provides lifelong health benefits. It’s a vaccination for life. Parents have the right to alter a child’s immune system and they also have a right to circumcise. There is no down side to circumcision in spite of your claims. And please stop talking about the pain because anesthetics deal with that. The only embarrassment is that other health organizations haven’t taken 5 years to research and evaluate the evidence but issue statements without any evidence to support what they say. The AAP indeed did a good job.. • SunkenShip says: Sounds like a member of the AAP taskforce is among us…. You say that HIV rates among heterosexuals in the U.S. is love and attribute that to circumcision. Are HIV rates among heterosexuals in the UK, Denmark, Japan, Spain, etc. higher than the U.S.? If not, then your theory is shot. And we already know that STDs aren’t higher in non-circing countries, so the theory you all keep preaching is junk. And who said that the medical societies issuing statements against circumcision HAVEN’T evaluated the evidence. That is an arrogant, stunning claim to make. Or do you only sling that mud because they didn’t reach the same pro-circ conclusion as the AAP? • Anonymous says: Whether or not you like my theory, my point is that you and others know that your claim about the high US circ rate and HIV is bogus. As whether or not other medical societies have evaluated the evidence, I have not seen any of them do in depth research saying what the evidence they evaluated and now. When they do something like the AAP did, their statements will have more credibility. And anyone who claims there are NO health benefits to circumcision is defying the high quality scientific research. • Researcher says: In the study [1], Laumann et al observed that circumcised men engage in a wider variety of sexual activity than intact men, and hypothesized that this was due to the social stigma associated with being intact. The data from which that study was derived [2] does not support that conjecture: it contains no data on attitudes toward the circumcision status of the respondents. Another conjecture is that circumcised men engage in a wider variety of sexual activity because they derive less satisfaction than intact men from the smaller subset of activities engaged in by intact men and are led to engage in compensatory activities. In the examples derived from [2] below, the higher likelihood of behaviors observed in circumcised men versus intact men cannot be explained by the putative social stigma associated with being intact. Calculations were derived using the two-sample z-statistic, in this case for proportions of intact and circumcised men who reach a certain threshold of behavior out of two populations of intact and circumcised men. Likelihood of masturbating to relieve tension The first finding is a higher likelihood of masturbating to relieve tension: 47% of circumcised men masturbate to relieve tension, versus 30% for intact men. The odds ratio is (.47/.53)/(.3/.7) = .89/.43 = 2.12. The statistical significance level is 0.024.* The inter-mean distance in units of standard deviation between the distributions of the two groups is 0.43. The likelihood of avoiding sex. The second finding is that among white, non-Hispanic men at least 55 years old, 68% of circumcised men had avoided sex (recently, at some point), versus 49% for intact men who had avoided sex. The odds ratio is (.68/.32)/(.49/.51) = 2.13/.96 = 2.22. The statistical significance level is 0.047.* The inter-mean distance in units of standard deviation between the distributions of the two groups is 0.48. *The p-values are one-tailed. 1. Laumann, Edward O.; Masi, Christopher M.; Zuckerman, Ezra W., “Circumcision in the United States: Prevalence, prophylactic effects, and sexual practice.” JAMA, The Journal of the American Medical Association. Apr 2, 1997, 277, (13), 1052 – 1057. 2. Edward O. Laumann, John H. Gagnon, Robert T. Michael, and Stuart Michaels. NATIONAL HEALTH AND SOCIAL LIFE SURVEY, 1992: [UNITED STATES] [Computer file]. ICPSR version. Chicago, IL: University of Chicago and National Opinion Research Center [producer], 1995. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 1995. APPENDIX: detailed analysis First analysis: the likelihood of masturbating to relieve tension. We find that 47% of circumcised men masturbate to relieve tension, versus 30% for intact men. The odds ratio is (.47/.53)/(.3/.7) = .89/.43 = 2.12. Respondents in the Laumann study were asked if they had masturbated to relieve tension. Our null hypothesis, denoted H0, is that there is no difference in the likelihood that intact or circumcised men will masturbate to relieve tension. If H0 were true, the observations in the samples of intact and circumcised men would come from a single population of men, of whom some proportion m will masturbate to relieve tension. Accordingly, instead of estimating separately the proportion pct of circumcised men who masturbate, and the proportion pit of intact men who masturbate, the two samples will be pooled to form the pooled sample proportion m: m = (# of circed and intact men who masturbate)/(# of observations in both samples combined) Next, we calculate the two-sample z-statistic for proportions z = (pit-pct)/\sqrt{m(1-m)(1/\mathrm{circed} + 1/\mathrm{intact})} and then use the standard normal distribution to find P-values. We use the open source statistical computing package R. Here is our R session, with the Laumann National Health Social Life Survey data: > myframe <- read.spss(file=’nhsls.sps’) > attach(myframe) > intact <- myframe[GENDER==”Male” & CIRCUM==”No”] > circum <- myframe[GENDER==”Male” & CIRCUM==”Yes”] > intact_tension <- myframe[GENDER==”Male” & CIRCUM==”No” & MAST12D==”Yes”] > circum_tension <- myframe[GENDER==”Male” & CIRCUM==”Yes” & MAST12D==”Yes”] > pit <- length(intact_tension)/length(intact) > pct <- length(circum_tension)/length(circum) > pit [1] 0.3067332 > pct [1] 0.4695731 > m <-(length(intact_tension)+length(circum_tension)) /(length(intact)+length(circum)) > m [1] 0.4260985 > z <- (pit-pct)/sqrt(m*(1-m)*(1/length(circed)+1/length(intact))) > z [1] -1.985958 > pnorm(z) [1] 0.02351897 Since pnorm(z) < .05, the results are statistically significant at the 5% level. This is evidence against the null hypothesis that circumcision has no sexual effect whatsoever, and so no difference in masturbatory behavior should be detected H0: pit = pct, and in favor of the alternative hypothesis that being intact reduces the likelihood of masturbating to reduce tension Ha: pit < pct. We are led to reject the null hypothesis. Second analysis: the likelihood of avoiding sex. We find that among white, non-Hispanic men at least 55 years old, 68% of circumcised men had avoided sex (recently, at some point), versus 49% for intact men who had avoided sex. The odds ratio is (.68/.32)/(.49/.51) = 2.13/.96 = 2.22. Respondents in the Laumann study were asked if they had avoided sex–we find that this effect increases with age. We consider the case of white, non-Hispanic males age 55 or above. Our null hypothesis H0 is that there is no difference in the likelihood that intact or circumcised men will avoid sex. We show that the null hypothesis may again be rejected. We continue our session in the open source statistical package R: > circumw <- myframe[GENDER==”Male” & CIRCUM==”Yes” & ETHNIC==”White, non-hisp.” & AGE >= 55] > intactw <- myframe[GENDER==”Male” & CIRCUM==”No” & ETHNIC==”White, non-hisp.” & AGE >= 55] > intactw_avoid <- myframe[GENDER==”Male” & CIRCUM==”No” & ETHNIC==”White, non-hisp.” & AVOIDSEX==”Yes” & AGE >= 55] > circumw_avoid <- myframe[GENDER==”Male” & CIRCUM==”Yes” & ETHNIC==”White, non-hisp.” & AVOIDSEX==”Yes” & AGE >= 55] > pia <- length(intactw_avoid)/length (intactw) > pca <- length(circumw_avoid)/length(circumw) > pia [1] 0.4864865 > pca [1] 0.675 The null hypothes is$latex H_0: pia – pca = 0\$. If the null hypothesis were true, the two populations would be part of the same population. Accordingly, instead of estimating separately the proportion pca of circumcised men age 55 or above who avoid sex, and the proportion pia of intact men age 55 or above who avoided sex, the two samples will be pooled to form the pooled sample proportion ma:
> ma <- (length(intactw_avoid)+length(circumw_avoid))/(length(intactw)+length(circumw))
> ma
[1] 0.5844156
As above, we calculate the two sample z-statistic for proportions and the corresponding P value.
za <- (pia-pca)/sqrt(ma*(1-ma)*(1 /length(circumw) + 1/length(intactw)))
> za
[1] -1.677017
> pnorm(za)
[1] 0.04676958
As in the previous example, P < .05, so at the 5% level we may reject the null hypothesis and accept the alternative hypothesis that circumcision increases the likelihood that a man age 55 or over will avoid sex.

Inter-mean distance in units of standard deviations

We compute the difference between the means of the distributions of intact and circumcised men. For the case of masturbating to relieve tension, we have the proportion pit of intact men who masturbate to relieve tension, and the proportion pct of circumcised men who masturbate to relieve tension.
> pit
[1] 0.3067332
> pct
[1] 0.4695731
> qnorm(pct) – qnorm(pit)
[1] 0.4287887
For the case of avoiding sex, we have the proportion pca of circumcised men who avoid sex, and the proportion pia of intact men who avoid sex.
> pca
[1] 0.675
> pia
[1] 0.4864865
> qnorm(pca) – qnorm(pia)
[1] 0.487642
The value 0.4876 applies to men of age 55 or above; a value of .4151 is obtained for white, non-Hispanic men of age 45 or above.

These examples cast doubt on the hypothesis of Laumann that the wider variety of sexual behaviors observed in circumcised men is due to the social stigma of being intact.

• Frederick Rhodes says:

One of the primary functions of the male and female prepuce is to cause sexual arousal when physically stimulated. The benefits of circumcision only apply after a physical problem has been caused. There are no health benefits to religious, ritual, or routine infant circumcision, only financial, medical and phychological benefits. Education on the physiological functions, proper hygiene and safe uses of the male and female prepuce is more desirable for a life time of prevention, pleasure and health. This so called high quality scientific research was specially designed to justify infant circumcision, a powerful ancient religious superstitious ritual sacrificial punishment hex for adults having sex incorrectly. Think of it like dentistry. Would you allow yourself to be fooled into allowing your dentist to pull all your childs teeth to prevent the possibility that something may go wrong if he doesn’t?

• SunkenShip says:

When the “health benefits” fail to play out in the REAL WORLD, then yes, it’s absolutely fair to question whether they really exist.

If circumcision’s health benefits are real, show me the population data that shows that the UK, Europe and the rest of the non-circumcising world has:

– Higher instances of STD infection than the US
– Higher levels of HIV infection than the US
– Higher levels of urinary tract infections than the US
– Higher levels of penile cancer than the US

I’ll wait for you to round up that information. Then we can talk about circumcision’s supposed health benefits.

• Joseph4GI says:

Circumcision hasn’t stopped HIV in our own country.
http://data.unaids.org/pub/Report/1998/19981125_global_epidemic_report_en.pdf

And, it hasn’t stopped other STDs either.
http://www.reuters.com/article/2009/01/13/us-infections-usa-idUSTRE50C5XV20090113?pageNumber=1&virtualBrandChannel=0

In America, the majority of the male population is circumcised, approximately 80%, while in most countries in Europe, circumcision is uncommon. Despite these facts, our country does poorly.

In fact, AIDS rates in some US Cities rival hotspots in Africa. In some parts of the U.S., they’re actually higher than those in sub-Saharan Africa. According to a 2010 study published in the New England Journal of Medicine, rates of HIV among adults in Washington, D.C. exceed 1 in 30; rates higher than those reported in Ethiopia, Nigeria or Rwanda.
http://www.nejm.org/doi/full/10.1056/NEJMp1000069

The Washington D.C. district report on HIV and AIDS reported an increase of 22% from 2006 in 2009. According to Shannon L. Hader, HIV/AIDS Administration, Washington D.C., March 15, 2009, “[Washington D.C.’s] rates are higher than West Africa… they’re on par with Uganda and some parts of Kenya.” Hader once led the Federal Centers for Disease Control and Prevention’s work in Zimbabwe.

http://www.washingtonpost.com/wp-dyn/content/article/2009/03/14/AR2009031402176.html

One would expect for there to be a lower transmission rates in the United States, and for HIV to be rampant in Europe; HIV transmission rates are in fact higher in the United States, where most men are circumcised, than in various countries in Europe, where most men are intact. It is telling that the HIV epidemic struck in our country in the 1980s, 90% of the male population was already circumcised. Somehow, we’re supposed to believe that what didn’t worked in our own country, or anywhere else, is going to start working miracles in Africa.

• Joseph4GI says:

The AAP did “in depth” research… If you can call cherry picking and script reading “in depth…”

Remember; the AAP is not the only medical organization out there. There a others, and they have access to the same exact data, and they found it lacking.

The trend of opinion on routine male circumcision is overwhelmingly negative in industrialized nations. No respected medical board in the world recommends circumcision for infants, not even in the name of HIV prevention. They must all point to the risks, and they must all state that there is no convincing evidence that the benefits outweigh these risks. To do otherwise would be to take an unfounded position against the best medical authorities of the West.

I’m afraid the AAP stands alone.

No one is claiming there are no “health benefits” to circumcision, only that they are not sufficient to endorse circumcision for all boys. Not even the AAP does, which really pisses you off, doesn’t it Brian.

• Passing Stranger says:

Actually it sounds more like Jake Waskett, a commonly encountered pro-circumcision loon noted for spamming web articles on circumcision. More info: http://www.circleaks.org/index.php?title=Jake

• Petit Poulet says:

Anonymous,

I am afraid you are mistaken. The rates of HETEROSEXUALLY-transmitted HIV is three to four times higher in the United States than in Europe. While heterosexually transmitted HIV is low in the US compared to Africa, it is still much higher than in Europe.

Circumcision is not working in Africa. Uganda was able to cut their HIV incidence in half using the ABC (Abstinence, Be faithful, Condoms) program. Now the focus and money have been channelled in to circumcision programs. Guess what? The HIV incidence in Uganda is rising again. Throughout Africa men are getting circumcised under the impression that they don’t have to wear condoms anymore. Circumcision is a dangerous distraction when it comes to reducing HIV in Africa, or anywhere else.

The anesthetics given to infants do not provide adequate anesthesia. In two trials they tried the same techniques on adults undergoing circumcision and they halted both studies because it was clear that the anesthetics didn’t work. The difference is that we can easily restrain an infants so the procedure can be done regardless of how well the anesthetic works. Also nothing is given for postoperative pain.

The Task Force has embarrassed the AAP and its membership

• Anonymous says:

Got any evidence to support your claims?

The task force did an excellent job and the only people
who should be embarrassed are those who deny reality.

• Michelle says:

How do you know that African HIV isn’t also transmitted primarily through homosexuality and injections? Bailey admitted they didn’t track the source of the infections. Heterosexual transmission occurs about 1 out of 1000 sexual acts, so isn’t likely to be the cause of the epidemic over there. Ugandan officials already are seeing an increase in HIV because of no money for other prevention since all going to circumcision.

The AAP did a horrible job, which is easily shown.

• Anonymous says:

No, the AAP task force did an excellent job based on science.
I just love the way you anti-circ folks choose your words — “admitted”, as if to say yeah you’re really right,

There will never be evidence that’s 100% foolproof. One has to rely on large scale studies which have
been done to the satisfaction of everybody but those who think circumcision is inherently wrong.

• Joseph4GI says:

No, the AAP didn’t do anything except read their lines handed to them by Tobian, Gray et al. They seem inept at what they’re talking about.

So they “don’t recommend” it, but parents should still be able to “choose?” AND the state should pay for it?

What kind of non-committal self-serving bullshit is that?

And who is “everybody?” You and your circumcision club?

• Petit Poulet says:

Anonymous,

I assume you have the wherewithal to look up the HIV incidence and prevalence rates published by the World Health Organization. The numbers are published, go look them up. It is not my job to spoon feed you or wipe your butt.

• Joseph4GI says:

Maybe the task force might provide us with more “evidence” besides the cherry-picked garbage which supports their financial and religious interests?

• Mary Lanser says:

You are an idiot. Circumcision is a vaccination for life??? You fail to mention that a condom is necessary to complete your claim. No downside to circumcision? Just tell that to the thousands of men and boys who suffer from complications and harm from unnecessary genital alteration! You also need to educate yourself on your anesthesia claim. Until you can ask a newborn how well the “anesthesia” is working….you have no right to make such a claim! You must have been assisting in the brainwashing in Africa….since that is exactly what many African men believe….that their circumcision is an “invisible condom”! What baloney and it’s no a vaccination either. What is an embarrassment is that just two short years ago, the AAP was advocating for a “ritual nick” on the genitals of infant girls UNTIL they became very unpopular with anti FGM activists and RETRACTED that statement! How embarrassing for a pediatric health organization to have their integrity already firmly questioned two years ago, and now with the recent re statement……they have further embarrassed themselves! The AAP indeed did NOT do a good job, AGAIN!

• Anonymous says:

Mary, in case you don’t know, vaccinations aren’t 100% effective either.

The only people embarrassed should be you deniers of the health benefits of circumcision.

The task force is standing on solid scientific evidence.

• Joseph4GI says:

Brian, could you tell us how circumcision is anything LIKE a vaccine?

Deniers of “benefits?”

How about deniers of harm and human rights?

THAT should be embarrassing to snake oil hucksters such as you…

The “task force” is standing on scientific rubbish; the smut of peer reviewed journals.

• Seamus says:

• Seamus says:

• Seamus says:

• Joseph4GI says:

There is only one person who uses the term “foreskin worshipers,” and “surgical vaccine,” and that is none other than circumfetishist Brian Morris. And he does a terrible job as trying to impersonate people oth than himself.

Tell us, Brian, what about other countries in Africa where this “protective effect” is not observed? Are they all homosexual needle users there too? 10 out of 18, according to USAID.

You can’t explain away ALL instances where circumcision fails.

How does circumcision effect the human immune system, eh? Could you give us a detailed scientific explanation to this claim?

You might as well say garlic “is working” to keep vampires away.

How is it parents have a “right” to something no one, not even the AAP can bring themselves to endorse?

Pain is a red herring; all surgery is “less painful” with analgesics. Most other surgery is medically indicated because other treatment has failed.

The trend of opinion on routine male circumcision is overwhelmingly negative in industrialized nations. No respected medical board in the world recommends circumcision for infants, not even in the name of HIV prevention. They must all point to the risks, and they must all state that there is no convincing evidence that the benefits outweigh these risks. To do otherwise would be to take an unfounded position against the best medical authorities of the West.

I’m afraid it is the AAP who is going out on a limb making claims that no other medical organization has made.

• So how do you explain the very similar low rate of heterosexual HIV acquisition in non-circumcising Europe?

All that is working in Africa is the campaign to circumcise. In Zimbabwe, more of the circumcised men had HIV than the non-circumcised men, both in 2005 before a circumcision campaign and in 2010-1 after it.

The AAP did a rotten job.

• Heather says:

Is circumcision the most effective way to reduce HIV transmission even if you believe that the 1.3% reduction is an accurate and reliable statistic? No, even the researchers themselves admit that it is not a “vaccine” and that men still need to use condoms to prevent HIV transmission. Even if circumcision did approach the effectiveness of a vaccine, it still would not be ethical to circumcise infants who can not consent to the procedure. It is a normal, healthy, functional body part that is permanently removed. A man may never be at risk for HIV in his lifetime, but it is decided for him at the moment of his birth that he is not responsible enough to keep all of his body parts. We circumcise in the U.S. for cultural and religious reasons. It has nothing to do with health, which is precisely why the rest of the world does not agree with us.

• intersex says:

In The Five Sexes, Anne Fausto-Sterling wrote about the need to extend the traditional male/female sex dichotomy to a continuum with five distinguished sexes: females, ferms, herms, merms and males. In The Five Sexes Revisited, Fausto-Sterling wrote that intersexuals had effectively advocated on behalf of the right to uninterrupted sexual development and had helped to shift the prevailing medical consensus away from early reassignment to psychological counseling. This is in marked contrast to the efforts of males and so-called intactivists, whose assertion of an equal right to uninterrupted sexual development is stigmatized as a preposterous attempt to find some moral equivalence between penile reduction surgery and female genital mutilation. There is even the suggestion is that it is anti-feminist to suggest that female genital mutilation is in any way morally relevant to routine infant circumcision.

If one believes in a continuum, one can no longer presuppose a strict gender dichotomy when justifying the genital cutting of males but prohibiting the non-therapeautic genital cutting of females. I don’t know the extent to which such a move could be morally persuasive. I suppose a moral particularist could say that ultimately the decision to circumcise is based on a priori considerations whose relevance could never be established on empirical grounds.

Let’s take a moral theory less sophisticated than Dancy’s moral particularism: Gert’s moral theory. On a Gertian account, circumcision violates certain moral rules and therefore has to be justified according to a two-step procedure for justifying violations. However, the controversy surrounding routine infant circumcision blocks a straightforward claim that the procedure is morally justified: roughly equal numbers of equally-informed, impartial, rational persons support and oppose routine infant circumcision. In that case the justification is at best weak. This is not an uncontroversial case of amputating an arm to save a life. Gert’s theory allows that weakly justified violations may be punished. This suggestion will be unpopular with parents. The case of routine infant circumcision does not bode well for Gert’s moral theory, if I have read him correctly.

While I agree with Brian Earp’s superior argument, I am not sanguine that any argument will prove persuasive, in the end.

• Petit Poulet says:

Last time I checked, female genital mutilation is a genital reduction surgery, and male circumcision is also a genital reduction surgery. So how are intactivists different than intersexuals who have advocated for the right to uninterrupted sexual development? Your premise makes no sense. All children have the right to uninterrupted sexual development, why are youe differentiating between females and males? Is there a viable defense for maintaining a gender dichotomy?

Your premise that roughly equal numbers of equally-informed, impartial, rational persons support and oppose routine infant circumcision is baseless. The truth is that men who were circumcised as infants tend to support infant circumcision while intact men overwhelmingly oppose infant circumcision. So much for being impartial. Sarah Waldeck has written an interesting paper noting that circumcision status in males affects their ability to be rational about this issue. Since when are moral issues popularity contests. This is a step toward moral relativism.

While the argument given by Brian Earp is strong, these decisions are not based on information or rationality, but on emotion and the primordial need to look like others.

• intersex says:

FGM, circumcision and genital cutting are all forms of genital reduction surgery. They vary. There seems to be general opposition to the assertion of a moral equivalence between FGM and circumcision. I chose genital reduction, but perhaps genital alteration is a better term. I want to avoid certain ideological discussions that seem to imply that because of the broader context of womens’ oppression and the medical opinion commonly expressed that FGM is more sexually debilitating than circumcision, that one cannot even think that males have a right to uninterrupted sexual development. I think they do, and I am dismayed by ideological moves that act to silence legitimate claims to bodily integrity.

So how are intactivists different than intersexuals who have advocated for the right to uninterrupted sexual development?
Good question. I wonder myself how it is that intersexuals managed to have their voices heard by the medical establishment, but men and intactivists have not had the same success. I point out that if there is a continuum, then this tends to undermine attempts to marginalize the male claim to uninterrupted sexual development if females and intersexuals have been successful. I seem to be whistling in the wind.

Your premise that roughly equal numbers of equally-informed, impartial, rational persons support and oppose routine infant circumcision is baseless. The truth is that men who were circumcised as infants tend to support infant circumcision while intact men overwhelmingly oppose infant circumcision. So much for being impartial.

This begs the question against impartiality. An impartial judge does not vary his or her judgment of some action as a function of who is performing the act. They may judge differently–as long as they make the same judgment. The controversial aspect of the subject should cast doubt on claims that routine infant circumcision ought to be morally obligated. This is not a “popularity contest” but a reflection of how moral judgment is distributed on the matter. Some issues are controversial; others are not. Amputating an arm to save a life is not controversial, if you follow Gert (or not). There are violations of moral rules (do not cause pain, do not disable, do not limit freedom) that such a surgery involves, but this is mitigated by other morally relevant features–the arguments are standard and not worth repeating. Genital alteration in the absence of a medical condition lacks these features. (I’m leaning toward moral particularism these days, but that’s another matter.)

Now I would like to point out some of my own research. Data supporting

In the study [1], Laumann et al observed that circumcised men engage in a wider variety of sexual activity than intact men, and hypothesized that this was due to the social stigma associated with being intact. The data from which that study was derived [2] does not support that conjecture: it contains no data on attitudes toward the circumcision status of the respondents. Another conjecture is that circumcised men engage in a wider variety of sexual activity because they derive less satisfaction than intact men from the smaller subset of activities engaged in by intact men and are led to engage in compensatory activities.

In the examples derived from [2] below, the higher likelihood of behaviors observed in circumcised men versus intact men cannot be explained by the putative social stigma associated with being intact.

Calculations were derived using the two-sample z-statistic, in this case for proportions of intact and circumcised men who reach a certain threshold of behavior out of two populations of intact and circumcised men.

Likelihood of masturbating to relieve tension
The first finding is a higher likelihood of masturbating to relieve tension: 47% of circumcised men masturbate to relieve tension, versus 30% for intact men. The odds ratio is (.47/.53)/(.3/.7) = .89/.43 = 2.12. The statistical significance level is 0.024.*

The inter-mean distance in units of standard deviation between the distributions of the two groups is 0.43.

The likelihood of avoiding sex.
The second finding is that among white, non-Hispanic men at least 55 years old, 68% of circumcised men had avoided sex (recently, at some point), versus 49% for intact men who had avoided sex. The odds ratio is (.68/.32)/(.49/.51) = 2.13/.96 = 2.22. The statistical significance level is 0.047.*

The inter-mean distance in units of standard deviation between the distributions of the two groups is 0.48.

*The p-values are one-tailed.

1. Laumann, Edward O.; Masi, Christopher M.; Zuckerman, Ezra W., “Circumcision in the United States: Prevalence, prophylactic effects, and sexual practice.” JAMA, The Journal of the American Medical Association. Apr 2, 1997, 277, (13), 1052 – 1057.

2. Edward O. Laumann, John H. Gagnon, Robert T. Michael, and Stuart Michaels. NATIONAL HEALTH AND SOCIAL LIFE SURVEY, 1992: [UNITED STATES] [Computer file]. ICPSR version. Chicago, IL: University of Chicago and National Opinion Research Center [producer], 1995. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 1995.

I can go through these calculations in detail. My point is that if one looks at the data, you do find support for loss of function and behavioral changes. That won’t satisfy ideologues, and I have more or less given up. Even people ostensibly on my side become almost irrationally critical and hostile if they detect the slightest deviation from their opinion. It’s not worth my time. The experience has left me somewhat more withdrawn, I must say.

• The Intactivist movement is opposed to all non-therapeutic, non-consented genital alteration, male, female or gender (re)assignment of people with Variations of Sexual Development (VSDs). The Intactivism Pages include a page about intersex. It was Intactivists (led by Intact America) who led the charge against the AAP’s proposal to allow a token, ritual nick to girls “much less extensive than neonatal male genital cutting” in 2010, resulting in them backing down within a month.

Laumann’s findings, such as they are, can be taken either way. If you think circumcision is a good thing, “circumcised men are more adventurous about sex” but if you think it is a bad thing “circumcised men are seeking more variety because they’re enjoying it less”.

• Dr G Scott says:

Bravo, Brian. Keep it up. The AAP has just lost the respect of many people in the U.S.A. and I hope your work helps prevent needless pain and death to future American baby boys.

• Anonymous says:

The AAP only lost the respect of those opposed to circumcision. Those who evaluate the research objectively
applaud the 5 years of research the AAP did and respect their conclusion.

I think the problem is that people against circumcision realize this is a big loss for their cause
and they’re trying to figure out how to discredit the AAP task force.

If circumcision really does reduce the risk of HIV and other STD’s as many studies of the years indicate,
they what you think is a worthy cause is going to cost people their lives.

Cut it out!

• Petit Poulet says:

Actually the AAP has embarrassed itself on the world stage. Several other countries have looked, much more closely, at the medical literature and have come to the exact opposite conclusion. Why is that? Pretty simple they didn’t have committees that had were made up entirely of circumcised men or women who belonged to religious traditions that require infant circumcision. The Task Force has done a terrible disservice to the AAP and it members. Those opposing circumcision do not have to discredit the AAP Task Force, the Task Force did a great job to discredit themselves with their biased, incomplete analysis. The quality of the report is an embarrassment: well below the standard of AAP reports. The documentation is shoddy, the review of the medical literature incomplete, and their conclusions are not supported by the incomplete, biased information they did present.

If the Task Force makes you feel better about being circumcised, then it has accomplished something positive.

I do have an homework assignment for you. It has two parts. First, read the RCT from South Africa and explain to me how 23 of the men who became HIV-mfected during the trial did so even though they either did not have sexual intercourse or always used a condom. Second, read the RCT form Uganda and explain to me how the men who always used a condom had a higher risk of HIV-infection than men who never used a condom. When you answer these questions, you can come back and we will discuss the matter.

• Martin C. says:

Since you seem only interested in making pot-shots and no real arguments, I will make my comment brief. There are basically three large RCTs that indicate circumcision might potentially reduce HIV/STDs, all three coming from Africa and performed on a population that no intellectually honest person could possibly compare to US infants. All three have major flaws, as Brian wrote about previously, a post which you might wish to check out. Even if there is some initial reduction in HIV transmission directly attributed to circumcision status, none of the RCTs showed any population level impact in Africa, calling into question the wisdom of rolling out circumcision programs even in high level epidemic regions. A number of the authors of the RCTs are also the prime proponents of increased insurance coverage for circumcision in the US, ignoring well documented counter-evidence that circumcision has no visible impact on HIV status anywhere on the planet. Their mathematical models would only be useful if they analyzed a highly efficacious procedure (90-95% efficacy) for reducing HIV rates. Still, the RCT authors (namely Tobian and Grey) insist that their modeling reflects the real world, particularly the health outcomes of US infants. For reasons stated above, this is preposterous, considering that the US has completely different vectors of HIV transmission and that much of the developed world does not suffer from higher HIV rates or any other ailment that circumcision supposedly reduces. Given these facts alone, it is absolutely fair to criticize the AAP statement, especially when neither the risks or benefits have been properly quantified as the AAP’s own technical report admits.

• SunkenShip says:

So the medical organizations of other first-world countries who are taking hardline stances against the practice are just bumbling idiots?

You do yourself a disservice when you pretend like the AAP is the only “informed” organization on the issue, just because they’re squarely in the pro-circ camp.

• Mary Lanser says:

Oh yeah, cut it out……how poetic. It’s clear that your intention is to keep on cutting, regardless of the harm. There is no respect for a pediatric health organization who two years ago advocated for a ‘ritual nick” to the genitals of infant girls….then retracted it out of unpopularity due to anti FGM activists! Now with this recent ridiculous circumcision statement…..they will lose all credibility. You don’t even sound that certain that circumcision will reduce the risk of HIV and STD’s……which it doesn’t, or countries like Japan would be dying off in droves! They aren’t, and that is fact. Why are you such an advocate of genital cutting and altering on babies? I have to really wonder what is behind that.

• Anonymous says:

It is truly a waste of time to argue with all of you.
No evidence no matter how compelling will
change your minds. You don’t even consider the evidence
for the health benefits of circumcision as valid.

For what it’s worth, I was circumcised as an adult
in my 20’s. I know both sides of the issue.
Sex is better circumcised and the (non-existent)
“function” of the foreskin is made up by you.

• Joseph4GI says:

Is there a number of “studies” or “benefits” that might convince you to support female circumcision?

Yes, I’m sure it’s all about “who can get the most studies in.”

Why, this is a “study” producing contest.

If you can produce the most number of “studies” in your favor, you “win” right?

Is that why many of the “studies” are basically rehashings done by the same authors?

• Joseph4GI says:

This has GOT to be no other than Brian Morris. (He is known for impersonating…)

I’ve got news for you; the AAP stands alone with their new stance that “the benefits outweigh the risks.”

The trend of opinion on routine male circumcision is overwhelmingly negative in industrialized nations. No respected medical board in the world recommends circumcision for infants, not even the AAP, not even in the name of HIV prevention. They must all point to the risks, and they must all state that there is no convincing evidence that the benefits outweigh these risks. To do otherwise would be to take an unfounded position against the best medical authorities of the West.

Why did the AAP stop short of endorsing circumcision like you hoped?

Perhaps there are at least a few people within the AAP who knew that the AAP was going to embarrass itself, and not recommending it was going to be their one saving grace.

If circumcision prevents HIV, it needs to breach person’s choice.

80% of all American men a circumcised, yet the US has higher HIV transmission rates than many countries whe circumcision is rare. This tells us that circumcision is worthless in the fight against HIV.

Would you mind telling us, right here on this blog, the scientific explanation as to how circumcision affects HIV at all? Maybe circumcision causes the brain to start releasing Langerhin into the blood stream? Maybe HIV has foreskin detecting alleles that cause it to self destruct upon sensing it’s absence?

Tell us what no “researcher” has thus far been able to do.

• Seamus says:

• intersex says:

FGM, circumcision and genital cutting are all forms of genital reduction surgery. They vary. There seems to be general opposition to the assertion of a moral equivalence between FGM and circumcision. I chose ‘genital reduction’, but it is no entirely trivial to choose terms that make assumptions explicit and do not beg the questions one would like to investigate. You seem to prefer enthymeme to inference. The term FGM interferes with analysis because of the broader context of womens’ oppression and the medical opinion commonly expressed that FGM is more sexually debilitating than circumcision. Sometimes arguments against involuntary routine infant circumcision are taken to presuppose that the worst cases of FGM and routine male involuntary circumcision are equivalent. I think that males have a right to uninterrupted sexual development, and I am dismayed by ideological moves that act to silence legitimate claims to bodily integrity.

“So how are intactivists different than intersexuals who have advocated for the right to uninterrupted sexual development?”

This question is exactly why I mentioned the work of Anne Fausto-Sterling. I wonder myself how it is that intersexuals managed to have their voices heard by the medical establishment, but men and intactivists have not had the same success. I point out that if there is a continuum, then this tends to undermine attempts to marginalize the male claim to uninterrupted sexual development if females and intersexuals have been successful. I seem to be whistling in the wind however. I do not presuppose a dichotomy. You seem to want to think that I do.

“Your premise that roughly equal numbers of equally-informed, impartial, rational persons support and oppose routine infant circumcision is baseless. The truth is that men who were circumcised as infants tend to support infant circumcision while intact men overwhelmingly oppose infant circumcision. So much for being impartial.”

This begs the question against impartiality. An impartial judge does not vary his or her judgment of some action as a function of who is performing the act. They may judge differently–as long as they make the same judgment independently of the group to which the judgment applies. The controversial aspect of the subject should cast doubt on claims that routine infant circumcision ought to be morally obligated. This is not a “popularity contest” but a reflection of how moral judgment is distributed on the matter. Some issues are controversial; others are not. Amputating an arm to save a life is not controversial, if you follow Gert (or not). There are violations of moral rules (do not cause pain, do not disable, do not limit freedom) that such a surgery involves, but this is mitigated by other morally relevant features–the arguments are standard and not worth repeating. Genital alteration in the absence of a medical condition lacks these features. (I’m leaning toward moral particularism these days, but that’s another matter.)

Not all circumcised men want others to be circumcised: many do not, and some men attempt foreskin restoration. Unfortunately there seem to be no studies of this, but anecdotal accounts suggest the recovery of some lost function.

Now I would like to point out some of my own research.

In the study [1], Laumann et al observed that circumcised men engage in a wider variety of sexual activity than intact men, and hypothesized that this was due to the social stigma associated with being intact. [2] does not support that conjecture: it contains no data on attitudes toward the circumcision status of the respondents. Another conjecture is that circumcised men engage in a wider variety of sexual activity because they derive less satisfaction than intact men from the smaller subset of activities engaged in by intact men and are led to engage in compensatory activities.

In the examples derived from [2] below, the higher likelihood of behaviors observed in circumcised men versus intact men cannot be explained by the putative social stigma associated with being intact.

Calculations were derived using the two-sample z-statistic, in this case for proportions of intact and circumcised men who reach a certain threshold of behavior out of two populations of intact and circumcised men.

The first finding is a higher likelihood of masturbating to relieve tension: 47% of circumcised men masturbate to relieve tension, versus 30% for intact men. The odds ratio is (.47/.53)/(.3/.7) = .89/.43 = 2.12. The statistical significance level is 0.024.*

The inter-mean distance in units of standard deviation between the distributions of the two groups is 0.43.

The second finding is that among white, non-Hispanic men at least 55 years old, 68% of circumcised men had avoided sex (recently, at some point), versus 49% for intact men who had avoided sex. The odds ratio is (.68/.32)/(.49/.51) = 2.13/.96 = 2.22. The statistical significance level is 0.047.*

The inter-mean distance in units of standard deviation between the distributions of the two groups is 0.48.

*The p-values are one-tailed.

1. Laumann, Edward O.; Masi, Christopher M.; Zuckerman, Ezra W., “Circumcision in the United States: Prevalence, prophylactic effects, and sexual practice.” JAMA, The Journal of the American Medical Association. Apr 2, 1997, 277, (13), 1052 – 1057.

2. Edward O. Laumann, John H. Gagnon, Robert T. Michael, and Stuart Michaels. NATIONAL HEALTH AND SOCIAL LIFE SURVEY, 1992: [UNITED STATES] [Computer file]. ICPSR version. Chicago, IL: University of Chicago and National Opinion Research Center [producer], 1995. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 1995.
URL: http://www.icpsr.umich.edu/icpsrweb/ICPSR/studies/06647

I can go through these calculations in detail. My point is that if one looks at the data, you do find support for loss of function and behavioral changes. That won’t satisfy ideologues, and I have more or less given up. Even people ostensibly on my side become almost irrationally critical and hostile if they detect the slightest deviation from their opinion or if I seem to them to be insufficiently intolerant. I take this as further evidence that the subject is controversial. In the end, it’s not worth my time to continue. The experience has left me somewhat more withdrawn, I must say.

• intersex says:

N.B. my remarks were in reply to le poulet présomptueux petite above. The phrase “no entirely non-trivial” should be “not entirely non-trivial” 0r just “non-trivial.”

• Ben says:

Well done Brian.

With this madness still going on in so many suppossedly enlightened countries it makes me feel so much better to know that intelligent and articulate people like you are going into battle with these inconsistent fools.

As Charles Mackay said in “Extraodinary Popular Delusions and the Madness of Crowds” : “Men, it has been well said, think in herds; it will be seen that they go mad in herds, while they only recover their senses slowly, and one by one.”

The fascination with circumcision since the middle of the last century would make a perfect new chapter to that book…

• Booker says:

Great article. I was very disappointed by the AAP statement and submitted an ‘E-letter’ in response. That was to the online version out last week. After submission I received an email saying that, if accepted, it would be online within a few days. It still isn’t there, but I haven’t received any notification that it was rejected. In addition, while there were 3 or so E-letters in reply to the online version, now that it’s officially ‘in print’ and listed in the current edition, those earlier E-letters seem to have disappeared.

I don’t know what’s going on here, I’ll give them a few days grace and then chase up whether they’re intending to list my response at all or see if those earlier responses re-appear. But it got me thinking, if Pediatrics is the official journal of the AAP, and you submit an article heavily criticizing an AAP policy statement, well, are they going to print something like that? It’s a huge conflict of interest. I may have to submit an opinion piece or likewise in a competing journal. Unfortunately for me this is an example of the problem with medical journals – when they don’t publish criticisms of the studies or pieces they publish, in my mind they fail to fulfill their role as mediums of scientific dissemination. It becomes yet another source of publication bias. Luckily in this day and age we have blogs to fill this gap to some extent.

• Susan says:

It is an interesting exercise to examine the arguments made on this page from a disinterested perspective, looking only for examples of the major logical fallacies and for weak inductive conclusions. Take or leave this advice as you like, but it’s a much better strategy to offer the best possible arguments, especially if you want to change hearts and minds. When you can reconstruct the opposing argument to be as strong as possible, and still manage to refute it, then you’ve presented a powerful case. That’s not happening here. Instead, you see things like people comparing circumcision to Mengele’s experiments, or suggesting that the AAP’s report is bogus because the head of the committee was Jewish. Who do you think is convinced by such appeals? Who do you think might be repulsed? Imagine that a pregnant woman who’s thinking about whether to circumcise has read the AAP report and checks out an article like this one for an alternative point of view. Are all the fallacies and emotional appeals supposed to persuade her that your scientific and medical understanding is more trustworthy than the AAP’s, as an authority? Something to ponder.

• intersex says:

I have attempted to argue from the perspective of different moral theories, and have performed statistical analyses, in particular, on the data ([2] above) that was used in published studies ([1] above). I find it interesting that many results that could have been published, such as those I mentioned, were not, or were explained away by an appeal to the social stigma of being circumcised. But my results show this could not have been the case. There is no social stigma in masturbating more to relieve tension if you are intact (unless all the respondents were doing this in public). An increased likelihood of masturbation is exactly the opposite of the behavior that circumcision was once intended to cure. And the social stigma of being intact has nothing to do with the greater likelihood of avoiding sex for any reason–circumcised older men do this. A better explanation that comports with the data is based on the change physiological function, some of which is immediate, and some of which is gradual over time. The means of the distributions of the two groups are about a half of a standard deviation apart on many measures. That’s a robust finding. So you will get some number of men who were adversely affected, but perhaps not enough for the subset of those who are vocal about it to have much influence.

You write that you are looking only for major logical fallacies and weak inductive analogies–perhaps mine were among them. I completely agree that the remark about the ethnic composition of the AAP task force was counterproductive–to be needlessly charitable.

But I have found, when discussing my own statistical findings, such as the higher likelihood of masturbation in circumcised versus intact men or the higher likelihood of avoiding sex among white males as a function of age (Hispanics had to be excluded as there were too few circumcised older men in the study [2] ), hostility even from those who believe that there is a right to uninterrupted sexual development.

The argumentation style you suggest–perfect examples of which may fail to persuade if one believes Kahneman that people aren’t persuaded by arguments but by people they trust–seems to elicit the charge of insufficient intolerance. I have more statistical findings (I began a decade ago), but because of the hostility I have encountered when attempting to represent the opposing arguments fairly, I gave up. That was in 2005. I’m reminded of the ungrateful attitudes again in 2012. And so my findings will remain in my filing cabinet.

Do you have potentially more persuasive arguments, yourself?

• Joseph4GI says:

I think it is important to show that the AAP has a conflict of interest.

While, at least ostensibly, the AAP is supposed to have the health and well-being as its priority, the organization is primarily a trade organization who must also protect the interests of its members, some of whom profit from infant circumcision, and others who have a religious conviction to circumcision.

It would be disingenuous to pretend like circumcision was this “innovative solution” which “researchers” *only* discovered yesterday.

Circumcision has been a problematic custom for Jews since Greco-Roman rule. Jews have tenaciously fought for the “right” to cut their children’s genitals for centuries. It is a custom to which Jews attach much meaning, and they clutch hard like a childhood teddy bear, and are reluctant to abandon.

For these reasons I think it is important for others to know people’s religious, if not ethnic affiliations.

Do “researchers” and “doctors” have the health and well being of children in mind? Are they interested in preserving their own income? Or are they merely interested in safeguarding s custom that is increingly under fire? (IE San Francisco, CA, Cologne, Germany, Denmark, etc…)

It would be ideal if people could separate their own bias from “research” and give us an “objective” evaluation. But that’s why it’s called a “conflict of interest.”

There are competing interests, and I think people should know about them.

You are either disingenuous or naive to be dismissing our pointing out of the disproportion of Jews involved in the “research” of circumcision and it’s advocacy.

Pointing out that favorable “whale research” is being produced by Japanese, who starkly defend killing 800 creatures s year as a “tradition” and “custom” is not “racist” or “anti-Japanese.” It is pointing out what is a conflict of interest which affects that “objectivity” we keep talking about.

From Wikipedia:
Conflict of Interest: Where a source seeks to convince by a claim of authority or by personal observation, identification of conflicts of interest are not ad hominem – it is generally well accepted that an “authority” needs to be objective and impartial, and that an audience can only evaluate information from a source if they know about conflicts of interest that may affect the objectivity of the source. Identification of a conflict of interest is appropriate, and concealment of a conflict of interest is a problem.

The conflict here is religious conviction to circumcision.

Ther are also people who profit from circumcision at the expense of healthy, non-consenting infants.

People ought to know about them.

• Susan says:

• It is not that Andrew Freedman is Jewish that suggests he is biased, but that he circumcised his own son on his parents’ kitchen table. This suggests an enthusiasm for the operation that goes beyond the normal.

My source:

Why is there such negative sentiment against circumcision?

[Dr Andrew Freedman:] I can’t really say. However, I can tell you that I’ve received thousands of e-mails over the years from parents telling me that circumcision is a terrible thing to do to a child, because of what they see as an overriding ethical principle of maintaining bodily integrity until the age of consent….

(As one person commented, “Well read them! That’s how you will be able to say! Duh!”)

Do you have a son and, if so, did you have him circumcised?

[Dr Andrew Freedman:] Yes, I do. I circumcised him myself on my parents’ kitchen table on the eighth day of his life. But I did it for religious, not medical reasons. I did it because I had 3,000 years of ancestors looking over my shoulder.

(And this does not create a conflict of interest?)

The Jewish Week, September 19. 2012

“Freedman was in breach of binding medical ethics by operating (if that is even the word) on his own son on his parents’ kitchen table. There are myriad reasons why one does not operate on a family member in a CLINICAL environment, (all of which are easily guessed at), let alone on a kitchen table. Many hospitals expressly forbid, for good reasons, surgery on family members, by those MD’s to whom they extend privileges.

Some questions (and they are many) include:

* Was Freedman actually ‘within the scope’ of an MD’s authority/ license at that moment? Or was he merely a mohel? How different is being a mohel from being a parent who learned the technique on the internet and wants to ‘give it a go’ ?

* Did Freedman have nursing backup, a crash cart, the ability to call a code ‘blue’?

* Did his medical malpractice insurance cover him and his partners?

* What remedy might the son have if he was botched and the insurance refused to cover the injury as ‘offsite and ‘outside the risk bargained for’?

* Who did the post-op observation? Anyone with medical training? To what risk was the child exposed thereby?

* A kitchen table is an inarguably septic surgery theatre. For his son’s sake, I hope they cleared off some of the breakfast dishes first or at least pushed them to one side.

“This demonstrates that these AAP-Task Force [people] have no sense of bioethics even as regards their own families, let alone the 1 million U.S. boys who must run their gauntlet every year.”

—-
There is certainly something Mengele-like about Maria Wawer el al.”s Rakai, Uganda, experiment (The Lancet, Volume 374, Issue 9685, Pages 229 – 237, 18 July 2009 “Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial”) in which she enrolled 922 HIV-POSITIVE men, circumcised half, and followed them to see if they would infect their female partners.

They would, MORE than the non-circumcised men, when they stopped the experiment “for futility” before it reached statistical significance. It would have been no more unethical to let it run and find out if there really was a direct correlation between circumcision and male-to-female transmission, but they weren’t looking for that.

• intersex says:

“Susan” isn’t so much interested in critical thinking as much as in impartiality toward Jews. But you don’t understand the difference between x% of men who masturbate to avoid tension and x% of men who masturbate. Kahneman has written about this kind of confusion.

• intersex says:

I wish there were an editing facility. It’s better to get into the habit of pasting comments prepared in a word processor, with text-to-speech and spell checking enabled. Corrections:

1) I find it interesting that many results that could have been published, such as those I mentioned, were not, or were explained away by an appeal to the social stigma of being intact.

2) is based on the change in physiological function,

3) non-whites and Hispanics had to be excluded as there were too few circumcised older men in this category in the study [2] ).

I am motivated by my own personal experience, but perhaps it is unwise to mention it. Now I am demotivated.

• Joseph4GI says:

‎5 years of mulling it over, and “We don’t recommend it, but it should still be an option for brainwashed parents, and the state should flip the bill.” was the best the AAP could do? Seriously?

Mr. Burns put it the best: “Spicy, yet spineless.”

• John Anon says:

Nice spin. The AAP said that based on the evidence (and there is a lot of it), the health benefits outweigh the risks and it should be an option for parents to consider.
They didn’t come one recommending it because there are other factors parents may want to consider which could out weigh the health benefits in the opinion of the parents.

You guys are sore losers. I didn’t see anybody respond as poorly as you do to the unjustified statements claiming there are no health benefits without anything to support that belief.

• Jack says:

I am a nursing student and am astonished that this still goes on while countries like Germany have outlawed the practice. Shame on the AAP for not firmly coming out on the side of truth and justice; and therefore, denying the innate right of every infant to grow up unscathed because of adult limitations and insecurity in protecting their infant sons from genital mutilation.

• John Anon says:

Get your facts right. Germany hasn’t outlawed circumcision. In fact, they’re looking at enacting a law to say it is legal to circumcise.

• HaWeHa says:

I warn everybody to take Male Genital Reductive Surgery lightly. Penises are very different, and even if the majority of “circumcised” men think they be “fine with it” there is others, that they will not. I provide my own testimony which is that (I thank my fate that) I was not submitted to this abominable “Surgery” bcz I REQUIRE my Prepuce, and the part of the RAPHE w/IN! the Prepuce respectively, for sexual function. I never climaxed as easily, and beyond doubt “Circumcision” would have a detrimental impact on me. I also have no doubt that there is countless circumcised men there, that these are substancially damaged (sexually reduced) yet do not raise their voice – out of shame, or by ill-understood solidarity with their Spiritual Community. Salut from Germany! Circumcised men, raise your voice against the Abomination, that it is now being asd esperately, PSEUDOSCIENTIFICALLY “endorsed” by Spiritual Friends of the Rabbinic “P”riestship. The cast, that wrote Circumcision into the Original Template of the Torah, the book of the “J”ehovist. Thus, including worship of a Pagan Fertility Cult into Holy Scripture, and having it appear, as if the Creator be commanding, to alter the perfect Creation. And, Christian Parents, if YOU think, “oh, Circumcision is sacred” then you are already wrong on TWO levels. Bcz Apostle Paulus had already uttered in clear terms.

• Keith says:

AAP = ignorance of the highest order. As a victim of genital mutilation, I was deprived from babyhood of what was my birthright, a fully-functional foreskin. Circumcision prevents nothing except normal sexual pleasure.

• John Anon says:

You are so lucky to have been circumcised at birth. I had it done in my 20’s and couldn’t wait to get rid of that nasty foreskin.
Circumcision enhances sexual pleasure.

• I suspect that people like John Anon are sufferers from a specialised case of anasagnosia – a neurological condition associated with lesions in the brain, causing the inability to recognise parts of one’s own body as one’s own, sometimes referred to as Anton’s Syndrome. Bizarre and dramatic when the part is an arm or a leg, the patient finds their own limb foreign and disgusting, and sometimes wishs to amputate it. (See “A Leg to Stand On” by Oliver Sacks, 1984, p 53) The possibility arises that this may apply to a man’s foreskin, resulting in a desire to be circumcised. It might also contribute to the feeling that one’s own foreskin was “nasty”.

I guess being rid of a body part that didn’t seem to be one’s own wouldenhance sexual pleasure.

• Anonymous says:

I left my son intact and then later was told he needed surgery for a hypospadius repair. (His openings to let urine out did not line up properly). I was worried that I made a mistake in leaving him intact but the doctor said I did the right thing. A hypospadius repair only takes *some* of the foreskin, so completely cutting away the whole thing simply isn’t necessary. So even when there is a medical issue, sometimes part of the foreskin can still be retained which is advantageous to men in adulthood. So I agree, keeping baby boys intact is good. If a medical problem comes up, you can deal with it then and might be able to do with less drastic measures.

• John Anon says:
• Michelle says:

Not. Find any study in the U.S. or developed country that supports that.

• John Anon says:

The observational studies support the health benefits of circumcision in the US.
There won’t likely be any more RCT’s. It would be unethical because of the known health benefits.

• RodC says:

I have read that in the three oldest known versions of the Torah that circumcision is not mentioned as being part of the covenant between God and Abraham. The circumcision requirement was inserted by the Jewish priesthood ca. 500BC – 1000 years after Abraham.

• Mikomikeyz says:

Pardon me if I question the motives of all information-spouters pro or con here. My initial impulse is to defend my own circumcision and my decision to circumcise my son. Of course, I see my body-image as perfectly healthy, and so does my son. My sex life is fine, my sensation I’ve never had reason to question, and judging from my boy’s proclivity to handle his dick. Neither does he. I was circumcised and had my son circumcised for what percieved health reasons and cultural ritual.

But clearly those who are equally self-content not being circumcised must feel that this has been an issue thrust upon them (cute pun), and resent it.

A man and his junk. This is fighting material. (Except it isn’t. We’re all just fine one way or the other.

What follows is a moral/philosophical/medical/religious soup of attack and counter attack to make the participant feel “CORRECT”. It isn’t too difficult to guess how many on the pro-circumcision “side” are circumcised, and how many on the “anti-circumcision side” aren’t. I direct you all to http://youarenotsosmart.com/2011/08/21/the-illusion-of-asymmetric-insight/

There needn’t be a “CORRECT” for everything. I don’t see much of a pressing issue for any society. If the issue is whether insurance should cover it, I’ll leave the rest of you to debate. I don’t care if I pay out of pocket.

I find the issue to lean toward the overly-dramatic. Witness, above , “Why it has produced a document so far out of line with both world opinion and the most basic of bioethical principles is a fascinating—and disturbing—question”, and “Long ago, the Aztecs feared that the sun would fail to rise if they did not make the annual sacrifice of human hearts in propitiation to Huitzilopochtli. But we know better than to mistake our cultural and religious habits for good science or medicine.”

Sorry, you can rebut all you want. I had a tonsillectomy at my parents’ desire, and I had braces on my teeth at their discretion. If you have no sense of scale, then you reduce the word “mutilation” and “barbarism” to meaningless.

So rather than patting each other for our smarts here, myself included, I say “Meh”.

Meh.

• Mikomikeyz says:

Pardon me if I question the motives of all information-spouters pro or con here. My initial impulse is to defend my own circumcision and my decision to circumcise my son. Of course, I see my body-image as perfectly healthy, and so does my son. My sex life is fine, my sensation I’ve never had reason to question, and judging from my boy’s proclivity to handle his dick. Neither does he. I was circumcised and had my son circumcised for perceived health reasons and cultural ritual.

But clearly those who are equally self-content not being circumcised must feel that this has been an issue thrust upon them (cute pun), and resent it.

A man and his junk. This is fighting material. (Except it isn’t. We’re all just fine one way or the other.)

What follows is a moral/philosophical/medical/religious soup of attack and counter attack to make the participant feel “CORRECT”. It isn’t too difficult to guess how many on the pro-circumcision “side” are circumcised, and how many on the “anti-circumcision side” aren’t. I direct you all to http://youarenotsosmart.com/2011/08/21/the-illusion-of-asymmetric-insight/

There needn’t be a “CORRECT” for everything. I don’t see much of a pressing issue for any society. If the issue is whether insurance should cover it, I’ll leave the rest of you to debate. I don’t care if I pay out of pocket.

I find the issue to lean toward the overly-dramatic. Witness, above , “Why it has produced a document so far out of line with both world opinion and the most basic of bioethical principles is a fascinating—and disturbing—question”, and “Long ago, the Aztecs feared that the sun would fail to rise if they did not make the annual sacrifice of human hearts in propitiation to Huitzilopochtli. But we know better than to mistake our cultural and religious habits for good science or medicine.”

Sorry, you can rebut all you want. I had a tonsillectomy at my parents’ desire, and I had braces on my teeth at their discretion. Both for perceived health reasons, both presently questionable. And both irreversible. If you have no sense of scale, then you reduce the word “mutilation” and “barbarism” to meaningless.

So rather than patting each other for our smarts here, myself included, I say “Meh”.

Meh.

• Martin says:

It isn’t too difficult to guess how many on the pro-circumcision “side” are circumcised, and how many on the “anti-circumcision side” aren’t.

Really? Not too difficult? It would be fascinating to know what your supposition is.

I’ve been involved with “intactivism” for 30 years, and from my experience knowing hundreds of men who oppose circumcision of healthy children, more than 90% are themselves circumcised. In fact, I know hardly any intact men who care about the circumcision issue at all, as long as it doesn’t personally affect them or their family. But your curious statement suggests that circumcised men defend circumcision and it is predominantly intact men that oppose or attack it. And that would be absolutely incorrect.

And how exactly are your tonsillectomy or former braces on unmistakable display whenever you’re naked in the locker room or the bedroom? Circumcision without a medical diagnosis is cosmetic surgery, plain and simple. Health claims about circumcision come almost exclusively from researchers and associations from English-speaking countries that at one time had very high circumcision rates and now have a neurotic, defensive middle-aged male population missing part of their penis. The rest of the world knows that there are no health benefits to circumcision, as an easy check of sexual health statistics among OECD countries reveals. Nonreligious circumcision was a fad, nothing more. Asserting it confers clear health benefits is either dishonest or wishful thinking.

• Not only that, but circumcision is surgery with definite risks and harms, and the default medical position is not to do surgery, certainly not on a newborn, and not on someone with no diagnosis (though some doctors put “born male” in the diagnosis box of the claim forms).

• Brother K says:

“Pardon me,” Mikomikeyz, “but your Apathy is showing.” Meh! Meh! Excuse my cough…!

“My initial impulse is to defend my own circumcision and my decision to circumcise my son.”

Of course it would be. That is the initial reaction of a victim of genital mutilation. No man wants to face the reality that his genitalia isn’t fully functional.

http://www.circumcision.org/satisfied.htm

=====

“I had a tonsillectomy at my parents’ desire, and I had braces on my teeth at their discretion. Both for perceived health reasons, both presently questionable. And both irreversible. If you have no sense of scale, then you reduce the word “mutilation” and “barbarism” to meaningless.”

And *both* of them would have been for clear/immediate issues that apparently needed ‘correction’ for whatever reason. Cutting off a perfectly healthy foreskin does not compare to having troublesome tonsils removed (they don’t cut out healthy ones) or having improperly aligned teeth corrected.

=====

“So rather than patting each other for our smarts here, myself included, I say “Meh”.”

No, you don’t. Not really. What you actually did was spend eight paragraphs basically doing what you said your initial impulse was — which you then tried to pretend you weren’t acting upon, but in reality you were.

• Heather says:

It must be difficult though to face the fact that you had a healthy, functional, normal body part of your own body removed without cause, then perpetuated that abuse onto your son due to your own insecurities. I am so thankful that my husband was confident and mature enough to recognize and honor the rights of our sons to live their lives with their whole, healthy bodies even though he was denied it himself.