Podcast: The Ethics of Infant Male Circumcision

In this talk (audio- MP3 and video -youtube)  , Brian D. Earp argues that the non-therapeutic circumcision of infant males is unethical, whether it is performed for reasons of obtaining possible future health benefits, for reasons of cultural transmission, or for reasons of perceived religious obligation. He begins with the premise that it should be considered morally impermissible to sever healthy, functional genital tissue from another person’s body without first asking for, and then actually receiving, that person’s informed consent—otherwise, this action would qualify as a criminal assault. He then raises a number of possible exceptions to this rule, to see whether they could reasonably serve to justify the practice of infant male circumcision in certain cases.

First, what if it could be established that the risk of contracting certain diseases might be diminished by removing a person’s foreskin in infancy, as is often suggested in the United States? Second, what if circumcision could be shown to reduce the spread of AIDS in African populations with high transmission rates of HIV? Third, what if the infant’s parents believed that they had a cultural or a religious obligation to remove the foreskin from his penis before he was old enough to give his consent?

After discussing the merits of these considerations as possible “exceptions” to the ethical premise with which he began, he concludes that they do not present compelling justifications for circumcision before the boy is old enough to understand what is at stake in such a surgery and to decide for himself whether he would like to part with his own foreskin. He concludes with a discussion of the similarities and differences between male and female forms of genital cutting, andsrgues that anyone who is committed to the view that infant male circumcision is morally permissible must also accept the moral permissibility of some (though not all) forms of female genital cutting. However, as he argues, neither type of cutting should be allowed absent clear consent of the individual and/or strict medical necessity.

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30 Responses to Podcast: The Ethics of Infant Male Circumcision

  • Michael Glass says:

    Thanks for publishing the sound recording of Brian Earp’s address. However, the address had visual aids which, of course, weren’t available on the podcast. Perhaps in future it would be better to make a video recording so that the on-line audience could also see at least some of the visual aids. This is of particular importance when maps and charts are used.

  • Tinashe says:

    Thanks for discussing the issue. I am a medical student and at the moment in my country there is an increase in infant circumcision and talking to some parents, you realise that they are not well informed about the matter but are just following the crowd.

  • Stephen Moreton Ph.D. says:

    Misleading anti-circumcision propaganda.

    Brian Earp’s propaganda piece for the anti-circumcision lobby is a mixture of misleading claims, unreliable “studies” and emotional rhetoric, with enough reasonable arguments thrown in to conceal the deficiencies and turn the listener against ALL infant circumcision. Where he is absolutely right is his criticism of religious and ritual circumcisions, with no regard to pain control, or good clinical practice. To circumcise because of tradition, or a religious belief the boy may later abandon, is stupid and irrational. African-style circumcisions and Jewish sucking of blood, are barbaric and wrong. They should be banned. Period.

    Otherwise his piece is highly misleading, and calculated to make circumcised males feel bad. This is a great recruitment ploy, but is misleading and unethical. Done properly, circumcision makes no difference to sexual function, and Earp’s arguments on this matter are pure pseudoscience.

    The foreskin is NOT erogenous. When men are asked to rank the different parts of the penis according to sexual sensation, they put the glans first, the foreskin last (Schober et al, 2009).

    The “touch sensitive nerves” argument is a favourite of anti-circs. What they never do is provide a control. How does the foreskin compare with other body parts? There are actually more of these nerves, per square cm, in the feet than in the foreskin, and they are bigger too. Are feet erogenous? Bhat et al (2008) compared 8 different areas of glabrous (hairless) skin and found fingertips to have the most (and largest) of these nerve endings, foreskins the fewest (and smallest). Earp does not tell his audience THAT! It is genital corpuscles that mediate sexual sensations, and these are not found in the foreskin.

    He tells us that the perineal nerve gets damaged and that this can cause erectile problems. Circumcision does not cause erectile problems, as shown by a recent meta-analysis (Tian et al, 2013), so speculations about the perineal nerve in this regard are moot.

    The glans becomes thicker, he says. False. This canard usually refers to the thickening as “keratinisation”. When skin from the glans is stained and examined for keratinisation no difference is found between circumcised and uncircumcised organs (Szabo & Short, 2000).

    He refers us to a survey in the British J Urol. 1999, and admits it was “self-selected”, but does not tell us just how self-selected. NOHARMM, a noisy anti-circ group, sent out its own questionnaire “formulated from details of circumcision damage reported by men who had contacted circumcision-related organizations” to men who had contacted “circumcision-related organizations”. Many of these organisations were foreskin restoration groups. In fact half of the participants were involved in foreskin restoration. In short they sent out a list of loaded questions to men already massively biased against circumcision! A more obvious example of a biased study would be hard to come across (only there are other examples, and by anti-circ groups too).

    Another outrageously biased piece of work is the next “study” Earp tries to trick his audience with: the “2012 global survey of circumcision harm”, which draws from just 8, mostly English-speaking, countries. 43 % of the respondents to this worthless propaganda exercise became aware of it through an anti-circ organisation. A further 17 % through friends and family who, likely, would know of their acquaintance’s interest. 71 % were from USA – the heartland of the anti-circumcision movement. So straight away it is drawing its respondents from a subset of circumcised men who are dissatisfied with their circumcisions, and/or massively biased against the procedure! Only 58 % described themselves as heterosexual, leaving one wondering just how grotesquely unrepresentative this “survey” is. It comprises an immense list of negative statements the participants are invited to respond to. A more biased, loaded method of eliciting a predetermined conclusion, from an already hugely biased sample would be hard to envisage.

    Both these “studies” are utterly worthless and should be ignored. For a proper, peer-reviewed, scientific appraisal of the current, best evidence for circumcision and male sexual function see the recent meta-analysis by Tian et al, (2013). They found that circumcision makes no significant difference! Earp is just trying to scare circumcised men into believing they have been damaged. A great way to gain angry and motivated recruits, but mean, cruel, and damaging to their self-esteem.

    When discussing the risks/benefits of the procedure Earp resorts to horror stories. But what about those who suffer ghastly consequences from NOT being circumcised? There are cases of loss of glans, penis, or life, following gangrene from paraphimosis. Or loss of life from AIDS, cancer … Any argument about risks has to be balanced by the risks of NOT circumcising.

    Earp again peddles discredited anti-circ “studies” when trying to play up the risks. Like the “117 USA babies die each year from circumcision” legend. This came from an article by circumcision opponent Bollinger, and was refuted my Morris et al (2012a). This citing of discredited claims and “studies” is common practice by circumcision opponents.

    Earp claims a 5 to 20 % risk of meatal stenosis. One does not even have to go further than good old Wikipedia to spot the cherry-picking here. What about the 0.01 % of English boys in Cathcart et al (2006)? In fact estimates of meatal stenosis vary wildly, and there is not even a consensus about how often it occurs in the uncircumcised (it does, don’t believe any anti-circ who says otherwise), and there is even the possibility of under diagnosis in the latter group as it may be harder to spot with a foreskin blocking the view. Meatal stenosis has long been regarded as subjective and tricky to define and diagnose consistently, with differences of opinion even as to its significance Belman (1978).

    It is laughable that Earp should attempt to attack the APA’s finding that the benefits outweigh the risks by suggesting some sort of cultural bias, because the APA’s doctors come from a circumcising culture, but the disagreeing European ones do not. Can he really not see the glasshouse from which he has just thrown his stone? The argument can simply be reversed. The European doctors come from a non-circumcising culture, and so may have a cultural bias against the procedure.

    Earp’s claim that there is no evidence that infant circumcision is effective against HIV is outrageous and irresponsible. If adult circ protects, why not infant circ? And it will protect more because the male comes already prepared, whereas if he waited until old enough to consent he may already have commenced sexual activity, and got infected. Any circumcision then would be closing the stable door after the horse has bolted. There is already evidence that the younger the age of circumcision the greater the protective effect, perhaps due to there being less scarring (Kelly et al, 1999).

    There are many reasons why infant is preferable over adult circumcision (Morris, et al 2012b). If we applied anti-circ logic to vaccination, and waited until an age of consent, we would still have smallpox.

    The anti-circumcision movement is built on scare-tactics, misleading claims, outright falsehoods and emotional rhetoric. It is a dangerous anti-medical, pseudoscientific movement akin to the anti-vaccinators and HIV/AIDS deniers (who often support it). It is psychologically damaging to circumcised males by needlessly, and falsely, making them feel they are damaged goods. And by undermining anti-HIV drives it costs lives. Whatever the rights or wrongs of circumcising babies, be deeply suspicious of it.

    References:

    Belman, A.B., Filmer, B.B., Immergut, M.A., Schoenberg, H.W. (1978) Pediatrics, 61:778-80

    Bhat, G.M., Bhat, M.A., Kour, K. & Shah, B.A. (2008) Density and structural variation of Meissner’s Corpuscle at different sites in human glabrous skin. J Anat Soc India, 57(1), 30-3.
    Cathcart, P., Nuttall, M., Meulen, J., Emberton, M., Kenny, S.E. (2006) Trends in paediatric circumcision and its complications in England between 1997 and 2003. Brit J Surg. 93:885-90.

    Kelly, R., Kiwanuka, N., Wawer, M.J., et al (1999) Age of male circumcision and risk of prevalent HIV infection in rural Uganda. AIDS, 13, 399-405.

    Morris BJ, Bailey RC, Klausner JD, et al.: (2012a) A critical evaluation of arguments opposing male circumcision for HIV prevention in developed countries. AIDS Care. 24:1565-1575.

    Morris, B.J., Waskett, J.H., Banerjee, J., Wamai, R.G., Tobian, A.A.R., Gray, R.H., Bailis, S.A., Bailey, R.C., Klausner, J.D., Willcourt, R.J., Halperin, D.T., Wiswell, T.E. & Mindel, A. (2012b) A “snip” in time: what is the best age to circumcise? BMC Pediatrics, 12, article 20.

    Schober, J.M., Meyer-Bahlburg, H.F., Dolezal,C. (2009). Self-ratings of genital anatomy, sexual sensitivity and function in men using the ‘Self-assessment of genital anatomy and sexual function, Male’ questionnaire. BJU Int., 103:1096-1103.

    Szabo, R. & Short, R.V. (2000) How does male circumcision protect against HIV infection? BMJ., 320, 1592-4.

    Tian, Y., Liu, W., Wang, J.Z., Wazir, R., Yue, X. & Wang,K.J. (2013) Effects of circumcision on male sexual functions: a systematic review and meta-analysis. Asian J Androl., in press.

    • Dear Dr. Moreton,

      Thank you for your commentary. If I may, let me address some of the criticisms of my talk that you have raised:

      1. My talk is not calculated to make circumcised men feel bad. I’m from the U.S.; most of my friends are circumcised; I don’t have any interest in making any of them feel bad about their penises. Most men I know who have been circumcised don’t mind that they had this operation performed when they were infants, while a substantial minority do mind. My aim was to present an ethical case against infant circumcision, not to hurt anyone’s feelings.

      2. The argument that circumcision makes no difference to sexual function is peculiar. How do you define “function” … ? If you mean that the ability to experience pleasure and to ejaculate is retained for most circumcised men, that is certainly true. But as I explained, the gliding and lubricating function of the foreskin is completely lost to circumcision, as is the ability to experience any of the sensations that stimulation of the foreskin provides. Any person who does, indeed, possess a foreskin can report on the pleasurable sensation it affords, especially through its rolling and gliding action during intercourse or masturbation. Whether the foreskin is “as sensitive” as other parts of the penis or body is a difficult question. First, foreskin sensitivity is likely to vary from person to person, as is the sensitivity of other parts of the body. Nerve distribution and density is not uniform across men; hence some men may have very sensitive foreskins, and others may have less sensitive foreskins. Yet anyone who has had his foreskin removed has zero sensitivity in the foreskin. Second, the Schober et al. (1999) study you cited affirms another of my points: these men had no history of genital surgery, meaning that they retained their foreskins. Thus the glans penis will have been protected (by the foreskin) in these men, retaining its softness and sensitivity. If the glans was rated as being particularly sensitive in these intact men, it’s because it would not have been exposed to rubbing and drying out. Sorrells et al. (BJU, 2007) had a better-designed study, as they compared intact to circumcised men, and showed that the glans was less sensitive in the circumcised men. This difference in glans sensitivity was also shown by Bronselaer et al. (2013), to pick just one additional recent study. So it isn’t just the sensitivity of the foreskin itself that is at stake, but rather the sensitivity of other parts of the penis which the foreskin evolved to protect (see Cold & McGrath, 1999). Of course, females have a prepuce (foreskin) as well — the clitoral hood — which serves the same protective function. You can imagine that some of the softness and sensitivity of the clitoris would be diminished if the protective skin around it were removed, causing it to rub against clothing and other environmental factors year after year, as does happen in some forms of female genital cutting, and as happens, analogously (i.e., to the glans) in male circumcision.

      3. Are the feet erogenous? Since you are a fan of Wikipedia, let’s use their definition: “An erogenous zone … is an area of the human body that has heightened sensitivity, the stimulation of which may result in the production of sexual fantasies, sexual arousal and orgasm.” As I’m sure you are aware, “foot fetishism” involves erotic response to feet and stimulation of the feet, and is, according to one study in the International Journal of Impotence Research (Scorolli et al., 2007), the most common sexual fetish. All this goes to show is that different people have highly different levels of sensation in different parts of the body, as well as different sexual and psychological responses to those body-parts; and many men have highly sensitive foreskins. Whether, in the aggregate, according to some (but not other) studies, the foreskin may be seen to be less sensitive than other areas of the penis – in within-subjects designs of intact men who have a protected (and thus highly sensitive) glans – is really beside the point. Any person without a foreskin has zero sensitivity in the foreskin; and yet this is sexually-responsive tissue he might be thought to be entitled to be able to stimulate without its being removed without his permission. This, again, is to ignore the basic functional (i.e., gliding and lubricating) properties of the foreskin, which are always lost to circumcision — “sensitivity” aside.

      4. You say that circumcision does not cause erectile problems, and cite a study by Tian et al. (2013). Let me quote the final sentence of the abstract from that study: “However, these results should be evaluated in light of the low quality of the existing evidence and the significant heterogeneity across the various studies. Well-designed and prospective studies are required for a further understanding of this topic.” In other words, the authors themselves admit that the quality of the evidence to support their claim is quite low. Other studies do show a decrement in erectile function (I wont list them here as they are too numerous to count; and, again, the quality of evidence in this area is dubious), and yet the basic point remains the same: the perineal nerve is frequently truncated by circumcision, especially when the frenulum is removed, and in these cases, the anatomical-mechanical basis for erection is compromised. The ideal study would be prospective, randomized-controlled, and would involve a comparison between intact men and circumcised men with (specifically) missing frenula, yet this study has not been conducted (and, in my view, would be unethical to conduct). In the meantime, we have to use our knowledge of anatomy combined with poor-quality correlation studies to triangulate the answer.

      5. Let’s talk about “keratinisation.” Does the glans become “thicker” after circumcision? First, this is not the main issue. The glans does become less sensitive (as has been repeatedly demonstrated) and it does become dried out. Whether it also becomes “thicker” is the least of our worries: it is the sensation of the glans that matters more for sexual experience. You cite a study by Szabo & Short (2000). They state: “There is controversy about whether the epithelium of the glans in uncircumcised men is keratinised; some authors claim that it is not, but we have examined the glans of seven circumcised and six uncircumcised men, and found the epithelia to be equally keratinised.” This is a passing comment in a wider study about circumcision and HIV, not an actual report of a peer-reviewed experiment. So, again, the authors that you yourself cite indicate that there is “controversy” on this question, and they offer as evidence an informal comparison that they made using a tiny sample size of N = 13, with no actual reporting of methods, data, and analysis. This is hardly convincing.

      6. You don’t like the studies I mentioned in which men reported feeling harmed by their circumcisions. Yes, these were self-selecting, and no, they are not representative. I stated quite clearly in my talk that I’d be happy to grant that most men who have been circumcised do not mind their status. Yet you missed the thrust of my argument. All I needed to demonstrate, for the purposes of the ethical analysis I was giving, was that there are a non-trivial number of men who DO mind, and mind in quite severe ways, that their genitals were operated on without their consent. Why? Because anyone who is not circumcised can always have his foreskin removed, if that’s what he would like; whereas the thousands upon thousands of men who resent having had their foreskins removed can never have them back. We don’t know the precise figures. Stating that you feel harmed by having been circumcised – especially if you are a male in a hetero-normative, masculinized, circumcising culture – is not likely to be a simple matter. That we know of as many cases as we do is enough to support the ethical point I was making. Part of interpreting the significance of studies is putting them in the context of the argument they are being used to advance. Here, you have criticized the studies as not being representative of the general population. Yet their representativeness was not relevant to the argument I was making.

      7. You state: “What about those who suffer ghastly consequences from NOT being circumcised? There are cases of loss of glans, penis, or life, following gangrene from paraphimosis. Or loss of life from AIDS, cancer … Any argument about risks has to be balanced by the risks of NOT circumcising.” There are number of things wrong with your analysis here. First, paraphimosis (in which the foreskin becomes trapped behind the head of the penis) is rare and almost always due to iatrogenic manipulation, but the key is that it’s easy to treat (Choe, 2000). Obviously any healthy part of the body can have some rare mechanical dysfunction: shoulders can become dislocated, fingers can become bent, toes can be stubbed. Yet if the “problem” is rare, and if it can be easily treated, then the idea of preventatively removing healthy and functional body parts becomes a farce. Penile cancer, too, is vanishingly rare, and can be prevented with basic hygiene (Frisch et al., 2013). As for AIDS, the data from Africa have been repeatedly called into question, and are, in any event, not applicable to epidemiological environments that are starkly different from the ones in which the studies were conducted (e.g., Svoboda & Van Howe, 2013). But the basic point is this. As I mentioned in my talk, the only medical authorities who think that the benefits of circumcision outweigh the costs (on balance) are those who are themselves circumcised and come from a circumcising culture. I address this point in some detail in another post, see here: http://blog.practicalethics.ox.ac.uk/2012/08/the-aap-report-on-circumcision-bad-science-bad-ethics-bad-medicine/.

      8. Meatal stenosis. For my figures I relied, not on Wikipedia, nor on a single study of a single population from 2006, but rather on a recent summary by Svoboda and Van Howe (2013). But, sure, the figures are hard to come by. Considering that circumcision is the most commonly performed surgical procedure, it is truly incredible that it is not regulated and that so little is known about the true rates of complication (Geisheker, 2013). There is quite a bit of room for improvement in regulation, oversight, and recording of surgical mishaps.

      9. On your point about the AAP and cultural bias, I have addressed that issue at length in another post: http://blog.practicalethics.ox.ac.uk/2012/08/the-aap-report-on-circumcision-bad-science-bad-ethics-bad-medicine/. As I wrote there: “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 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. Of course they are biased against such needless surgical risk.”

      10. There is indeed no evidence that infant circumcision protects against HIV, and certainly not circumcision of infants in the developed world. See the following articles for lengthy discussion of this point: Lyons (2013), Darby and Van Howe (2011), Frisch et al. (2013).

      11. You write: “The anti-circumcision movement is built on scare-tactics, misleading claims, outright falsehoods and emotional rhetoric. It is a dangerous anti-medical, pseudoscientific movement akin to the anti-vaccinators and HIV/AIDS deniers (who often support it).” I think you overstate your case here. Many of those who are opposed to circumcision are leading experts in child health and epidemiology, medical ethics, and legal theory. A recent paper opposed to circumcision, and published in the flagship journal Pediatrics 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 (Frisch et al., 2013). These authors stated unequivocally: “Only one of the arguments put forward by the American Academy of Pediatrics [in support of circumcision] 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.” There may, of course, be individuals who are opposed to circumcision who use overly emotional rhetoric, misleading claims and so on. But so are there individuals who are in support of circumcision who do the same. The worst offender in this regard is one Brian Morris, whom you cite a couple of times in your commentary with (evidently) a straight face. For more on Brian Morris, see http://www.circleaks.org/index.php?title=Brian_Morris.

      To conclude, I have thoughtful colleagues in ethics and medicine who think that circumcision is permissible; I have others who think that it is not. I appreciate respectful dialogue with those who disagree with my arguments in this domain. I have to say, however, that I find your own critique to be full of its share of “scare-tactics, misleading claims, outright falsehoods and emotional rhetoric.” I think that readers who listen to my talk, and then read your response to it, will have a good idea of which set of arguments is more level-headed.

      Sincerely,
      Brian D. Earp

      REFERENCES

      Bronselaer, G. A., Schober, J. M., Meyer‐Bahlburg, H. F., T’sjoen, G., Vlietinck, R., & Hoebeke, P. B. (2013). Male circumcision decreases penile sensitivity as measured in a large cohort. BJU international.

      Cold, C. J., & McGrath, K. A. (1999). Anatomy and histology of the penile and clitoral prepuce in primates. In Male and female circumcision (pp. 19-29). Springer US.

      Darby, R., & Van Howe, R. (2011). Not a surgical vaccine: there is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia. Australian and New Zealand journal of public health, 35(5), 459-465.

      Frisch, M., Aigrain, Y., Barauskas, V., Bjarnason, R., Boddy, S. A., Czauderna, P., … & Wijnen, R. (2013). Cultural bias in the AAP’s 2012 technical report and policy statement on male circumcision. Pediatrics, 131(4), 796-800.

      Geisheker, J. V. (2013). The completely unregulated practice of male circumcision: human rights’ abuse enshrined in law. New Male Studies, 2, 18-45.

      Lyons, B. (2013). Male Infant Circumcision as a ‘HIV Vaccine’. Public Health Ethics, 6(1), 90-103.

      Scorolli, C., Ghirlanda, S., Enquist, M., Zattoni, S., & Jannini, E. A. (2007). Relative prevalence of different fetishes. International journal of impotence research, 19(4), 432-437.

      Sorrells, M. L., Snyder, J. L., Reiss, M. D., Eden, C., Milos, M. F., Wilcox, N., & Van Howe, R. S. (2007). Fine‐touch pressure thresholds in the adult penis. BJU international, 99(4), 864-869.

      Svoboda, J. S., & Van Howe, R. S. (2013). Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision. Journal of medical ethics, 39(7), 434-441.

      • Hugh7 says:

        “Second, the Schober et al. (1999) study you cited affirms another of my points: these men had no history of genital surgery, meaning that they retained their foreskins. ”
        Wouldn’t you think? But no, Schober et al. also say “there were few (11) uncircumcised men in this sample”. Their cultural bias is so complete that they think circumcision is not genital surgery.
        “Men with a history of genital masculinizing surgery or genital excision surgery were excluded. Circumcision status was documented, but this genital surgery was not an exclusion criterion.” – the only time they admit that circumcision is genital surgery. If it had been an exclusion criterion, they would only have had 11 subjects! Circumcision of course is “genital excision surgery”.

      • Stephen Moreton says:

        The number, and in some cases length, of the replies to my post go to prove that the “Gish gallop” is not exclusive to creationists. And the swiftness with which they appeared is downright suspicious. I have even been honoured by one from Darby. Is there a Facebook call-to-arms I wonder? This practice of swarming over a dissenter, like a cloud of angry wasps after their nest has been poked, is a common tactic of “intactivists” as opponents of circumcision like to be called, and seems designed to intimidate the other side into submission.

        I have not the time to answer every detail in every Gish gallop the posters here batter me with. Nor every dubious study they try to cite or link to (odd how they never acknowledge the published critiques of those studies). Nor time to enter into a protracted debate although, in view of his nationality, surname and current affiliation, I suspect Mr Earp may relish a blog fight at the Oxford corral. I will, instead, clarify my position to avoid straw man attacks, and respond briefly to his main points to show why they are more pseudoscience than real science, and are indeed damaging and misleading.

        Firstly, I am not an advocate for routine infant circ. and never have been. If pushed I would probably go with the AAP and leave it to the parents, but would like to see more and better evidence. There remain grey areas that need to be resolved, and I have never said otherwise. The wildly divergent data on meatal stenosis is one example crying out for clarification. I readily accept that there is debate and division in the medical community on infant circ, routine or otherwise, and I am not here to advocate for it.

        Secondly, Earp et al need not lecture me about rolling and gliding of foreskins, and masturbation. I was a teenager myself once – with a foreskin. It and I parted when I was 30, and I have never regretted it, nor experienced any of the supposed negative effects intactivists warn about. Of course one example is not statistically significant, but I do, at least, have some experience to draw from. And yes, I had a choice, and I can see why some may be miffed that they didn’t, but the price I paid for that choice include a poorer cosmetic result, weeks of discomfort and inconvenience, increased risk of complications etc., etc.

        Thirdly, circ does not significantly affect function (more on which later) and it annoys me to see circ’d males being endlessly told that they are damaged and missing something important. No they are not! One of my reasons for entering this debate is to reassure my fellow “roundheads” that foreskins are greatly over-rated. Relax. You really are not missing much. Don’t believe the exaggerated, untested, and sometimes even just plain false, claims to the contrary.

        Fourthly, whatever the pros & cons of snipping babies, the intactivists badly need to get their house in order if they are to be taken seriously by the scientific community. This means getting their facts right. Avoiding presenting untested speculations as fact. Not exaggerating the alleged “damaging” effects of circ. Acknowledging published criticisms of the papers they cite (Earp and others here fail to do this, it is a very common failing). Avoiding simple logical fallacies (Mr Earp, please read about the “genetic fallacy” before you ramble on about circ’s origins as a cure for masturbation). Not relying on ridiculously biased surveys by biased authors on biased samples. Not making personal and ad hominem attacks on your opponents (like malicious smear campaigns against a certain Australian professor). Not bullying your opponents (posters here are not too bad, and Mr Earp is quite gentlemanly, but some of the name-calling I’ve seen elsewhere is appalling). Not lying to impressionable youngsters (or adults) to make them feel ruined. Not launching cyber-attacks on respected institutions when they publish results favourable to circ as happened to the Catalan Institute of Oncology in 2002 (would Mr Earp care to comment on the ethics of this?) And, for goodness sake, snap out of denial about the medical benefits of circ, particularly with respect to HIV. Circumcision DOES protect against HIV. Get used to it.

        Having said all that, I’ll run through Mr Earp’s points.

        Dear Mr Earp:

        1. “My talk is not calculated to make circumcised men feel bad”, you say. That’s not how it comes across. Try seeing it from the point of view of someone circ’d as a baby, with no foreskin experience, and unfamiliar with the literature. If I was such I would be deeply worried about your claims about nerves, gliding, thickening etc. and repeated statements about the foreskin being “erogenous”. When you keep rubbing it in how many things circ’d men are (allegedly) missing out on, how can it NOT make them feel bad? Yours’ is just a more sophisticated “sciencey” version of this post on another forum, aimed at a young lad who had been duped by anti-circ material and now resented his circ:

        “Your parents tortured you, mutilated you and left you with a dysfunctional penis … unless you restore your foreskin, you can never enter a woman’s vagina smoothly, nor will your penis protect her from chafing and the infections that can result from having sex with a circumcised man. In middle age, you may find that the sexual dysfunction will get worse”
        Sadly, this sort of callous rubbish is usual for intactivists, and is one of the reasons I have joined the debate after being on the side-lines for years, happy with my circ, and actually rather ambivalent about infant circ. It is mean, nasty and cruel. It would be ironic if many of the negative feelings (some) circ’d men report are a result of being subjected to this kind of insensitive crap on the internet. Do you regard the posting of such hurtful, and false, remarks to be ethical conduct? I don’t. I think it is disgusting and immoral. How must that poor kid have felt after reading THAT? And it is a story that is repeated over and over again all over the internet. It makes my blood boil.

        Here’s a suggestion. Tell intactivists to TONE IT DOWN! Qualify your arguments with the observation that many circ’d men, including those done as adults (like me) enjoy thoroughly satisfying and enjoyable sex lives. Any negative effects (and it is hotly debated that there are any) are slight. Reassure them that being circ’d is not a disaster, and some even prefer it (I do!)

        2. How do I define function? Well we can start with that meta-analysis by Tian et al. Sexual desire, dyspareunea, premature ejaculation, ejaculation latency time, erectile dysfunction and orgasm difficulties. None of which were significantly affected, as determined by looking at the ten best available studies. I will return to this study later.
        You tell us that foreskin owners can “report on the pleasurable sensation it affords, especially through its rolling and gliding action during intercourse or masturbation.” But this is mere anecdote. Equally there are men, like me, circ’d as adults and so able to compare, and who report on the wonders of the bare glans (personally I found it only a modest improvement). One can get anecdotal, personal testimonies for the wonders of anything from the latest snake oil remedy to the power of Jesus. Anecdotal evidence is the weakest of all, yet that is all you have as regards this wonderful gliding motion. What you need, and do not have, is hard experimental data on how many men experience it, what they think of it (they don’t all like it, you know), what their partners think of it, and whether the greater stimulation a bare glans receives compensates for it. In the absence of such data I am right to dismiss this gliding motion argument as mere speculation. That is all it is.

        You cite Sorrells et al, but follow the standard intactivist practice of ignoring the criticism of this study in which it was shown that the authors (who include Van Howe – more about him later) arrived at their desired answer by not doing their statistics right (Waskett & Morris, 2007). Intactivists will probably dismiss this critique because of who it was written by, rather than on the basis of its content. Ad hominem is so much easier, it saves you having to read up on what a Bonferroni correction is. And before you retort with Young’s reply (Young, 2007) be aware there are many problems with it. He even starts off with a straw man when he misunderstands the table W&M used, and is simply wrong about the need for a correction, amongst other problems.

        Here’s a couple of suggestions. Avoid anecdotes and personal testimonies, they are not science. Instead stick to hard data. And acknowledge published critiques pointing out the shortcomings of the studies you cite. Otherwise someone like me will throw them at you.

        3. Foot fetishists generally get off on the appearance of other people’s feet, not the sensations of their own. So they are irrelevant. The rich density and development of touch receptors on non-sexual parts of the body (feet, hands, finger-tips, forearms), and relative paucity and under-development of these in the foreskin, rather goes against any idea that these particular nerves are sexual/erogenous in function. To keep banging on, the way intactivists do, about these nerve endings is unjustified. It has simply not been established that they have any significant sexual role. That is untested speculation. At least you do not repeat the “20,000” urban myth. Well done.

        Here’s a suggestion. Acknowledge Bhat et al’s findings that foreskins are not particularly innervated with respect to touch receptors, compared to non-sexual parts of the body, and it is unknown what role, if any, the receptors it does have play in sex.

        4. I find your take on Tian et al extraordinary. Tian et al located 138 papers but had to exclude most because, variously, they did not compare sexual function with circ status, they were about female “circ”, the data sets were too small, they were about gay sex, they duplicated each other etc. They were left with 10, including the much touted Danish and Belgian ones (yes, Bronselaer et al are in there, with their unrepresentative self-selected sample – 12.1% of them gay, 22.6% cir’d in a country with a circ rate of 15% – see the two follow up critiques, and the reply to the first), and the African ones. Sure the number and quality of studies is limited, but what there is does NOT support the view that circ impairs any of the functions listed. If circ was as bad as the intactivists claim then it should have shown up in the meta-analysis. It does not. Any negative effect is so slight it is proving very elusive.

        Having dismissed Tian et al you then try to introduce “other studies” without telling us what they are, and conceding that their quality is “dubious”. This smacks of barrel-scraping. Suggestion: if they are “dubious” then don’t use them! In view of the comprehensive search Tian et al conducted it is likely these dubious studies of yours’ will have been examined and rejected anyway. Tian et al obviously understand the need for a little quality control. You want us to reject a meta-analysis of the best data, in favour of un-named studies that even you admit are “dubious”! Really Mr Earp, this is not good scholarship.

        Finally, you repeat your original, unproven assertion: that the supposed truncation of the perineal nerve compromises erection. But you have not even established that circ affects erectile function in the first place!

        Suggestion: until you can prove, with quality studies, that circ affects erectile function give up on this argument. I am reminded of a creationist website that has a list of “Arguments we think creationists should NOT use”, because they are just so bad. If intactivists ever list “arguments intactivists should not use”, I nominate the “truncated perineal nerve/erectile problems” speculation for inclusion.

        5. Keratinisation. To clarify, I meant the glans skin, rather than the whole glans, allegedly becoming thicker, but I think you understood that. You say, “First, this is not the main issue” and later “Whether it also becomes “thicker” is the least of our worries” and start emphasising instead that the glans loses sensitivity (something you have NOT established). Well if it is not the issue, then why do intactivists bang on about it so much? And why do they link it to this alleged desensitisation? In his (in)famous article in “Mothering” Fleiss, under the subheading “Circumcision desensitizes”, attributes this supposed desensitizing to “successive layers of keratinization”. And this gets parroted ad nauseam by almost every intactivist I come into contact with.

        Now I can find only one study in which the researchers actually took the time and trouble to compare the two glans conditions. And they found no difference. Now I would certainly like to see replication, and it surprises me that there seems not to have been such – unless you know different, in which case please enlighten me. But, in the absence of any other evidence all we have to go on is Szabo & Short. In short you have no proof that the glans skin thickens, and what little evidence there is says it does not.

        Suggestion: stop telling people the glans skin thickens until such time as you have the evidence to prove it.

        6. I reject totally the studies you mentioned for reasons given in my original post. At best they are tautologous. Select a sample of people who feel aggrieved about something, and ask them if they feel aggrieved. Lo and behold, many of them say they feel aggrieved. I don’t think it has ever been in dispute that some men are miffed about being circ’d. I often wonder how many of them feel this way because they have encountered misleading anti-circumcision material. And this is one reason why I am keen to rebut such misleading material, and reassure circ’d men that they should not be so concerned. This is independent of the rights or wrongs of them being circ’d in the first place.

        Suggestion: by all means state that some men are unhappy about being circ’d, it’s true. But have the humility to acknowledge that some of their concerns may be exaggerated, or unjustified, or the result of being deceived by misleading, exaggerated and speculative claims put about by opponents of circ.

        7. Medical pros & cons. Many cases of paraphimosis are not iatrogenic either, and if not caught swiftly it is very serious indeed. Penile cancer is NOT “vanishingly rare”, except in circ’d men. And HIV affects tens of millions. Yes, “the data from Africa have been repeatedly called into question”. Just as radiometric dating of rocks has “repeatedly been called into question” – by creationists arguing for a 6,000 year old earth. The arguments employed against the HIV trials, as with creationist arguments against rock dating, have all been debunked, in detail, and to the satisfaction of the WHO, CDC, UNAIDS …. They have been exposed as entirely vacuous. Once again you follow the usual intactivist tactic of ignoring published critiques. I have lost count of the number of times I have seen you people do this. Do I really have to point you to them? I note that you cite one of Van Howe’s latest works (co-authored with Svoboda). More about him shortly. As I said earlier, I am not here to advocate for infant circ anyway. I’ll leave that to the medics to battle out.

        Suggestion: be candid and acknowledge that circ does have benefits, especially with regard to HIV, and also acknowledge the rebuttals to the intactivists on this issue. The medical side of the debate then shifts to whether infant circ is justifiable on medical grounds. It may or may not be, and it may even depend on the country. That’s not a debate I’m entering into here, it’s not my purpose.

        8. Meatal Stenosis. I state in my introductory comments that there are grey areas that cry out for more research. This is one of them, but I would not use anything by Van Howe as a source (more later). Uncertainties like this are one reason I stay out of advocacy for infant circ. I concentrate instead on re-assuring circ’d males they are not missing much, and on correcting the more egregious errors and misbehaviour of intactivists (plenty to keep me busy there). Note that meatal stenosis is a relatively minor and easily treated condition, and can be entirely avoided by application of petroleum jelly in the months following circ.

        Suggestion: by all means point to uncertainties re risks etc. but do not state as fact that the meatal stenosis rate is 5 to 20 %. Nobody knows, and nobody knows the rate in the uncircumcised either. You’d be on firmer ground if you pointed to the wildly divergent figures, and argued that it is therefore difficult to estimate the occurrence of complications (at least this particular one).

        9. The cultural bias issue was also addressed by the AAP themselves in their rebuttal. See: http://pediatrics.aappublications.org/content/early/2013/03/12/peds.2013-0081.full.pdf+html

        10. It is perverse to assert that “there is indeed no evidence that infant circumcision protects against HIV” after the African trials. Everything that is understood about the likely mechanisms (and there are several) indicate that having a foreskin makes the male vulnerable. Why then should it matter if he loses the foreskin when a baby, or older? Do you seriously believe that African men circ’d as babies will have the same vulnerability as their uncut peers? So only Africans circ’d as adults will enjoy the protection demonstrated in those famous trials? I am struggling to keep a straight face here. What you are saying is just so silly. You then cite articles by circ opponents, including the notorious Van Howe. Two of these are too recent for critiques to have appeared (or if they have, I’ve not seen them yet). Perhaps they will in due course (Van Howe attracts them like iron filings to a magnet). The Darby and Van Howe one did attract a response and, in their reply, D & VH betray their pseudoscientific credentials by citing the discredited fringe claims that much African AIDS is not spread sexually. If that was part of the basis of their argument then it cannot be taken seriously. In any case all three papers you cite refer to HIV prevention in low HIV countries. I could cite other works to indicate that even then, circ may have a (obviously much reduced) impact but, as I said, I am not here to promote infant circ. It was Africa I originally had in mind anyway.

        Suggestion: stop denying, or downplaying, the protective effects of circ against HIV. It may not be as important in low-HIV countries, but in high HIV ones circ is saving lives big time.

        11. The anti-circ movement is indeed “built on scare-tactics, misleading claims, outright falsehoods and emotional rhetoric” and I provide plenty of examples here and earlier. You then employ the appeal to authority fallacy by citing an article by 38 “distinguished paediatricians” etc. Yes, I know this ploy. Creationists use it all the time. “Hundreds of distinguished scientists support the Biblical account of creation”. And climate change deniers too (their notorious “Oregon Petition” and similar publicity stunts).

        You admit “There may, of course, be individuals who are opposed to circumcision who use overly emotional rhetoric, misleading claims and so on.” Unfortunately that’s a great many of them, and is the other main reason I’ve stepped into the debate (reassuring circ’d males they are not damaged being the first). I have mentioned before the appalling and bullying way they behave. And I have exposed many misleading claims used by yourself. It is these things that really, really turn me off intactivism. As a long-standing atheist, religion-basher, and skeptic towards all manner of woo, I should be a natural ally. Instead the more I dig into intactivism the worse it appears, and the more apparent it becomes that the anti-circ movement is riddled with woo and badly needs to get its house in order. I hope you will read my criticisms in that light.

        Your link to the disgraceful circleaks website is just another example. It is pure ad hominem, personal attacks and smear campaigns. The page on Prof Morris opens with a hypocritical accusation about him allegedly trying to get someone sacked. What about the Facebook page trying to do the same to him? Or the similar attempts to get Daniel Halperin sacked? Remember the adage about people who live in glasshouses throwing stones. Then there is a crude and thoroughly scurrilous attempt to link him to Vernon Quaintance, who fell from grace in a child porn scandal. This is nothing but “guilt by association”. How was Morris supposed to foretell Quaintance’s disgrace? That Morris removed references to Quaintance promptly when the scandal broke was entirely right and proper of him. Would you prefer he retained them? I could point out that intactivists have had paedophile scandals too, and that the notorious NAMBLA is strongly anti-circ. Glasshouses and stones again.

        Suggestion: tell intactivists to remove these items from circleaks, or face charges of hypocrisy. Better still, they should close the site down. If you want opposition to circ to look respectable then stick to technical evidence and reasoned arguments, and rise above vulgar mud-slinging. I was disappointed with you when you stooped to citing circleaks.

        I could criticise specific individuals in the anti-circ movement, but based on technical issues, not personal attacks like on circleaks. I have mentioned Van Howe a few times here. Having read some of his works, including his latest “meta-analysis” (in IRSN Urology) purporting to show that circ does not protect against STIs (other than HIV), I have come to regard him as a serial offender in the misleading claims department. He has attracted an extraordinary number of rebuttals, and not all by Morris. He has even had the ignominy of having one of his blunders be used as a textbook example of the statistical trap known as “Simpson’s paradox”. He is the one who did a “meta-analysis” finding that circ increased the risk of HIV, whilst every other found the opposite. In one of his meta-analyses he cited data that was not in the four papers he claimed it was. When his critics pointed this out he conceded that data from one was “improperly extracted” and apologised. He did not account for the other three. In his latest “meta-analysis” he tries his sampling bias “correction” against HPV, but completely ignores the multiple critiques this argument of his has already attracted, including the devastating one by experts from the Catalan Institute of Oncology replying to his 2007 attempt to use this “correction”. The Catalan researchers concluded that his paper was so bad it ought to be retracted (Castellsagué, 2007). Ignoring published critiques is habitual for intactivists. I could go on for pages about this man, but have made my point. Sloppy work like his will go down well with rank and file intactivists, but not with those who take the time and trouble to investigate. Amongst the scientific community it only serves to undermine the credibility of the anti-circ movement. People like Van Howe scoring own goals all the time are your own worst enemy.

        Suggestion: NEVER trust anything written by Van Howe.

        Hopefully you will take on board my criticisms here, and see them as constructive, and as good advice, which is how I’d like them to be taken. And please act on my suggestions. They might spare you embarrassment in future debates should you come up against someone who has done his homework and discovered that much of what the anti-circs say is baloney. This applies especially to the published critiques. If you cite Van Howe, Sorrells, Bronselaer etc., without mention of the critiques, but your opponent knows of these critiques, you will just get them fired back at you. My criticisms of the anti-circ movement are all entirely valid. It is bullying, emotional, laden with fallacies, denialism, and sloppy scholarship. It does harm circ’d males – just look at the disgusting way that poor lad was treated in the example I gave near the start of this essay (in section 1). And, by attacking anti-HIV drives in Africa, it endangers lives. And this is all true whether it is good, bad or indifferent to circumcise babies. Please, do us all a favour and tell your fellow circ opponents to get their house in order. It is difficult to have respectful dialogue with representatives of a movement with so many things wrong with it. Thank you.

        References:

        Castellsagué X, Albero G, Cleries R, Bosch FX. (2007) HPV and circumcision: a biased, inaccurate and misleading meta-analysis. J Infect. 55(1): 91–3.

        Waskett JH, Morris BJ. (2007) Fine-touch pressure thresholds in the adult penis. (Critique of Sorrells ML, et al. BJU Int., 99, 864-869). BJU Int 2007; 99: 1551-1552.

        Young, H. (2007) Fine-touch pressure thresholds in the adult penis. BJU Int., 100, 699-701.

        • Dear Dr. Moreton,

          Thank you once again for your thoughts on this issue: I appreciate the time you’ve taken to elaborate on your original points (and to respond to mine as well).

          You’re right that this could drag on into an overly-long dispute, so I’ll try to be concise. With regard to your own experience, I won’t speculate about why you elected to be circumcised when you were 30, but to speak generally: if an adult chooses to part with his foreskin, assuming that he is not acting on a mere whim, it is because, for whatever reason, his particular foreskin (a) wasn’t doing much for him; or (b) had some sort of problem/issue associated with it. By contrast, men who have foreskins, but who wish to retain them (presumably) have a different experience: different foreskins are different, and different men have different experiences with their genitals. Thus, when you say that “foreskins are greatly overrated” you might be adopting an overbroad scope: for some men—and we don’t know how many; as we both agree, these figures are hard to come by—the foreskin is a source of great pleasure. Accordingly, one reason to leave circumcision to an age of consent is that each male can then respond to the particular situation he does in fact face. That is, men whose foreskins “don’t do much for them” can have them removed if they wish, while men whose foreskins are sensitive, confer great pleasure, are a source of delight, etc., can retain them.

          You state again that circumcision “does not significantly alter function” – and once again, I have a hard time tracking your meaning. The gliding and lubricating function of the foreskin is, I hope we can agree, completely eliminated by circumcision. Based on your choice of words, therefore, you must feel that this particular functional loss is not “significant” and, for you, it might not have been. For others, it is. Once again: since each person’s experience with (and relationship to) his own foreskin is quite variable, it seems reasonable to me to delay circumcision until such a time as the individual himself can weigh in on the desirability of such a surgery in light of his own particular anatomy and attendant preferences.

          You say that “intactivists badly need to get their house in order if they are to be taken seriously by the scientific community.” This is a confusing claim. Who makes up “the scientific community” … ? Are the large number of scientists – epidemiologists, health experts, etc. – who are opposed to circumcision on evidentiary (as well as ethical) grounds excluded from the scope of this term? Or by “intactivists” do you mean to describe only non-scientist circumcision opponents? In any case, there is a fast-and-loose relationship to facts among (some of) both circumcision supporters and skeptics—a problem that is undoubtedly compounded by the fact that “the facts” are (themselves) quite hard to pin down: the available data concerning many of the relevant questions are of poor or dubious quality. Experts on both sides of this issue, with equal access to “the facts” (insofar as they can be discerned) draw different conclusions with respect to their quality as well as to what they can reasonably be taken to show. So let us not imply that “the scientific community” has got it all sorted out, while the “intactivists” are making things up. In truth, there are distinguished “intactivist” scientists as well as airheaded circ fanatics, just as there are thoughtful defenders of circumcision and overheated circumcision foes. It’s better to deal with specifics where we can. One point on which I unreservedly agree with you is that all parties to this debate should take care to argue more thoughtfully, more humbly, and with greater concern for genuine engagement. Shouting matches are good for no one.

          You peg me with the genetic fallacy because I began my talk with a discussion of the history of circumcision. Unfortunately, this is to impute to me an argument that I did not make. Of course, beginning with the history of any topic would seem to be a good starting place when giving an introductory lecture; yet at no point did I claim, nor, I think, even imply, that circumcision is—today—bad medicine simply because it happened to start out as bad medicine. I do maintain that it remains bad medicine, but I tried to establish this point on the back of contemporary data (whether you find those data convincing or not).

          Now, just as resorting to logical fallacies is a poor way of making an argument, so is accusing your interlocutor of resorting to logical fallacies when he hasn’t. This is the notorious “straw man” – and we can trade these accusations back and forth all day. The broader point is that the very argumentative tactics you decry in your remarks are, and have been, repeatedly hauled out and deployed by circumcision proponents as much as by those who oppose the practice. I would like to see more measured and productive language coming from all sides of this debate (as I stressed above).

          Since we are talking about overheated rhetoric … You say: “For goodness sake, snap out of denial about the medical benefits of circ, particularly with respect to HIV. Circumcision DOES protect against HIV. Get used to it.” I’m just not sure how to respond to this. One of my areas of research is on the philosophy of science, on how “facts” are generated, by whom, using what instruments, through what publication and editorial processes, under what cultural circumstances, and so on, and I’m afraid (therefore) that I can’t get too excited about scientistic appeals to “medical benefits” as conjured by a coterie of (mostly American) researchers who seem hell-bent on finding them. To pick just one point, the well-known publication bias against null findings (the “file drawer” effect) is by itself sufficient to cast doubt upon the proclaimed findings of “medical benefit” from the perspective of meta-analysis – setting aside cultural bias, financial conflicts of interest, and the extra-scientific career motivations of many of the researchers running these studies. It is noteworthy, I think, that medical experts from non-circumcising cultures are typically of the view that circumcision does NOT confer net medical benefits, particularly in Western societies with access to good hygiene. These doctors have access to the very same data that you (and I, and the AAP) have access to. Now, if I’ve Googled you correctly, you have a doctorate in inorganic chemistry and a penchant for collecting minerals. My own training, apart from my work in ethics, is in cognitive science and philosophy (including philosophy of science), and hence neither of us is particularly well-qualified to speak authoritatively about the medical evidence concerning neonatal circumcision and health benefits. I happen to find the analysis of European authorities on this matter to be more convincing and trustworthy, while you seem to be fond of the claims put forward by the American Academy of Pediatrics. Each of us must do our best, in the end, to study the relevant research in this area, to dig critically into the chaotic mess of conflicting studies, and draw the most plausible conclusion. We won’t end up with exactly the same view. But please do not pretend that the “medical benefits” are as cut and dried as you imply—not even with respect to HIV—as your position is in conflict with the analysis of the majority of physicians working outside of the United States.

          In any case, my talk was on ethics. I presented a view of the scientific evidence that is consistent with the view of European experts, but my argument does not depend upon the veracity of their analysis. Since there is clearly disagreement about the magnitude of both medical benefit and risk, my perspective is that circumcision should be delayed until such a time as the individual himself can weigh in on whether or not he would like to have his own foreskin removed. The majority of claimed benefits – by those who insist upon their (net) existence – do not, in any case, “kick in” until sexual debut, and are more effectively prevented anyway by condom use and by care in selection of sexual partners. I hope we can agree on that.

          You write: “Qualify your arguments with the observation that many circ’d men, including those done as adults (like me) enjoy thoroughly satisfying and enjoyable sex lives.” I hope you took care to listen to my lecture. In it, I said: “For people who say that an infant won’t consciously remember the trauma of being circumcised, that much is probably true. We do have reason to think that unconscious factors and long term changes in brain functioning might be happening, but there’s more research that has to be done to understand the extent. And, of course, a lot of infants grow up to become men who don’t particularly care that they were circumcised, or that even happen to like their penises without a foreskin for whatever reason. I have no doubt about those two points.” So I am afraid that you are saddling me with suggestions I have already “taken” …

          Anecdotal evidence is the least reliable form of evidence, that’s true. We have subjective reports from men who enjoy their foreskins, and subjective reports from men who, like you, prefer it when they’re removed. Since the very large majority of intact men decline to undergo circumcision—and since the prospect of removing one’s foreskin, if one is from a non-circumcising culture, is typically thought to be so absurd as not even to arise—we should be able to tentatively conclude that a non-trivial number of the world’s men appreciate having an intact prepuce. Here is my ethical argument in relation to this fact, and it’s the same one I’ve given before. Men who have foreskins, but who do not wish to have them can always have them removed. Men whose foreskins were removed in infancy, by contrast, but who resent this fact—and who would like to know what it would have felt like to experience sex/masturbation with a foreskin—are (unfortunately) left without recourse. Therefore, it makes sense to avoid performing needless genital surgery on healthy infants, so that they can decide later, when they’ve had the chance to see how they feel about their own foreskins, whether they’d like to have them removed or not.

          You say that it’s best to stick to “hard data” – but the data on circumcision aren’t all that hard. When they support your position, you seem to regard them as conclusive (or at least compelling); when they don’t, you don’t. But science is not conducted in a vacuum. It is not immune to cultural and personal influence, and we could swap study citations, and critiques and counter-critiques, until we’re both blue in the face. I don’t have the energy. Instead, I think we should recognize that the brunt of this discussion (and the purpose of my talk) is (and was) to discuss the ethical advantages in delaying circumcision until an age of consent. You missed my point about Tian et al. – it was to point out that our knowledge in this area rests upon dubious “hard” evidence, as Tian et al. state in their abstract, and that we therefore have to triangulate between our knowledge of anatomy and the poor quality data that are available. Thus there is ample room for competing hypotheses, one of which I advanced. I did go on to suggest an experimental design that would offer a more conclusive answer to the question at hand, but we don’t have that answer yet.

          With respect to keratinisation – OK. My ethical case does not hinge on this point, and I agree that more studies are needed to sort out what it is that’s really going on. You seem to be taking out some of your frustration with “intactivists” on me, but it would be helpful if you focused your criticisms on the evidentiary disputes that are most relevant to the thesis I defended in my talk.

          Again you reject the studies I cited in which men reported feeling harmed by their circumcisions. But again you missed the role of these studies in my argument. I don’t claim that these men are the majority, and I don’t claim that the samples were representative. All I claim(ed) is that a non-trivial number of men report feeling harmed by their circumcisions, and that it is therefore preferable to delay circumcision until an age of consent. Some men who wouldn’t otherwise feel bad about having been circumcised may indeed feel aggrieved because of what they learn on the internet – some of which may, indeed, be unreliable (although it’s very hard to tell what is reliable and what isn’t, and a lot of the junk on the internet is pro-circ propaganda). But let us not trivialize, either, the genuine suffering and resentment of many thousands of men who do indeed feel harmed by having been circumcised – not only when something “goes wrong” (in the sense of losing part of the head of the penis, or something like this) but also simply because part of their genitals were cut off without their permission. That’s reason enough, in my view, to delay circumcision until an age of consent.

          Meatal stenosis. I take your point. The numbers are indeed unreliable, the estimates vary widely, and the definition is murky as well. I’ll try to be clearer about this point in future talks and papers. But that estimates are as high as 20% in some populations is a cause for concern. Re: cultural bias and the AAP. I guess you didn’t read my post on that topic. In it, I addressed the AAP’s reply to the original European critique. See the link in my previous reply if you find that you have the time. Re: infant circumcision and HIV. There may be good reason, on theoretical grounds, to speculate that infant male circumcision would confer partial protection against HIV in environments with high base rates of heterosexual female-to-male HIV transmission, but there is, as yet, no “hard” evidence of this. I thought we were supposed to stick to evidence and not speculation? The only evidence we have is that adult circumcision in specific sub-Saharan epidemiological conditions may afford partial protection against female-to-male HIV transmission. On the other hand, circumcision may lead to increased HIV infection in females (Chao et al., 1994; Dushoff et al., 2011), and in any case, a condom must be worn whether one has a foreskin or not. To circumcise infants in the developed world, therefore, as a means of reducing rates of HIV-transmission, when there are different patterns of HIV transmission, among different sub-populations, with different baselines for healthcare and basic hygiene, would be unwarranted on grounds of the available evidence.

          I’m concerned about your accusation that I “appealed to authority” by mentioning the authors of the recent European critique of the AAP, and then went so far as to compare my gesture to the tactics used by creationists—a group that I hold in as much disregard as you do. You must know that you are being disingenuous here, and I hope you will be courteous enough to admit it. I was responding to your specific claim that the anti-circumcision movement is “anti-medical” and “pseudoscientific.” In this context, it is certainly meaningful to point out that, among those who are opposed to circumcision are well-respected pediatricians, pediatric surgeons, urologists, medical ethicists, and heads of hospital boards and children’s health societies with expertise in the matter. Why is this meaningful? To illustrate, let me draw a contrast with creationists. Creationists tend to point to a few fringe biologists or geologists who happened to cobble together a PhD (and who did so, on many occasions, specifically to acquire the veneer of scientific respectability), who work for institutions such as the “Discovery Institute” in Seattle because they can’t get jobs at mainstream universities, and who utterly lack the esteem of the very large majority of their colleagues. This doesn’t mean that they’re wrong of course (though I think it’s clear that they are); it just means that the “authorities” to which creationists appeal are not taken seriously by their peers. Now, here are the authors of the European commentary:

          Morten Frisch1, MD, PhD, Yves Aigrain2, MD, PhD, Vidmantas Barauskas3, MD, PhD, Ragnar Bjarnason4, MD, PhD, Su-Anna Boddy5, MD, Piotr Czauderna6, MD, PhD, Robert P. E. de Gier7, MD, Tom P. V. M. de Jong8, MD, PhD, Günter Fasching9, MD, Willem Fetter10, MD, PhD, Manfred Gahr11, MD, Christian Graugaard12, MD, PhD, Gorm Greisen13, MD, PhD, Anna Gunnarsdottir14, MD, PhD, Wolfram Hartmann15, MD, Petr Havranek16, MD, PhD, Rowena Hitchcock17, MD, Simon Huddart18, MD, Staffan Janson19, MD, PhD, Poul Jaszczak20, MD, PhD, Christoph Kupferschmid21, MD, Tuija Lahdes-Vasama22, MD, Harry Lindahl23, MD, PhD, Noni MacDonald24, MD, Trond Markestad25, MD, Matis Märtson26, MD, PhD, Solveig Marianne Nordhov27, MD, PhD, Heikki Pälve28, MD, PhD, Aigars Petersons29, MD, PhD, Feargal Quinn30, MD, Niels Qvist31, MD, PhD, Thrainn Rosmundsson32, MD, Harri Saxen33, MD, PhD, Olle Söder34, MD, PhD, Maximilian Stehr35, MD, PhD, Volker C.H. von Loewenich36, MD, Johan Wallander37, MD, PhD, Rene Wijnen38, MD, PhD

          And here are their respective titles and affiliations: 1Consultant, Statens Serum Institut, Copenhagen, and Adjunct Professor of Sexual Health Epidemiology, Faculty of Medicine, Aalborg University, Aalborg, Denmark; 2Professor of Pediatric Surgery, Hôpital Necker Enfants Malades, Université Paris Descartes, Paris, France; 3Professor and President of the Lithuanian Society of Paediatric Surgeons, Lithuania; 4Professor of Pediatrics, Landspitali University Hospital, Reykjavik, Iceland; 5Consultant in Pediatric Surgery and Chairman of the Children’s Surgical Forum of the Royal College of Surgeons of England, UK; 6Professor of Pediatric Surgery, Medical University of Gdansk, Gdansk, Poland; 7Consultant in Pediatric Urology and Chairman of Working Group for Pediatric Urology, Dutch Urological Association, The Netherlands; 8Professor of Pediatric Urology, University Children’s Hospitals UMC Utrecht and AMC Amsterdam, The Netherlands; 9Professor and President of the Austrian Society of Pediatric and Adolescent Surgery, Austria; 10Professor and President of the Paediatric Association of the Netherlands, The Netherlands; 11Professor and General Secretary of the German Academy of Paediatrics and Adolescent Medicine, Germany; 12Professor of Sexology, Aalborg University, Faculty of Medicine, Denmark; 13Professor of Pediatrics, Rigshospitalet, Copenhagen, Denmark; 14Consultant in Pediatric Surgery, Landspitali University Hospital, Reykjavik, Iceland, and Karolinska University Hospital, Stockholm, Sweden; 15President of the German Association of Pediatricians, Germany; 16Professor of Pediatric Surgery, Thomayer Hospital, Charles University, Prague, Czech Republic; 17Professor and President of the British Association of Paediatric Urologists, UK; 18Professor and Honorary Secretary of the British Association of Paediatric Surgeons, UK; 19Professor and Chairman of Committee on Ethics and Children’s Rights, Swedish Paediatric Society, Sweden; 20Vice President and Chairman of the Ethics Committee of the Danish Medical Association, Denmark; 21Practicing Pediatrician and Member of Ethics Committee of the German Academy of Pediatrics, Germany; 22Consultant in Pediatric Surgery and President of The Finnish Association of Pediatric Surgeons, Finland; 23Associate Professor of Pediatric Surgery, Helsinki University Children’s Hospital, Helsinki, Finland; 24Professor of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Canada; 25Professor of Pediatrics, Chairman of the Ethics Committee of the Norwegian Medical Association, Oslo, Norway; 26Consultant in Pediatric Surgery and President of the Estonian Society of Paediatric Surgeons, Tallinn, Estonia; 27Consultant in Pediatrics and President of The Norwegian Paediatric Association, Norway; 28Chief Executive Officer of the Finnish Medical Association, Finland; 29Professor and President of the Latvian Association of Pediatric Surgeons, Latvia;30Consultant in Pediatric Surgery, Our Lady’s Children’s Hospital, Dublin, Ireland, 31Professor of Pediatric Surgery, Odense University Hospital, Odense, 1Denmark; 32Chief of Pediatric Surgery, Landspitali University Hospital, Reykjavik, Iceland; 33Associate Professor of Pediatrics, Helsinki University Children’s Hospital, Helsinki, Finland; 34Professor and President of the Swedish Pediatric Society, Stockholm, Sweden; 35Professor of Pediatric Surgery, Dr. v. Haunersches Kinderspital, Ludwig-Maximilians Universität, Munich, Germany; 36Professor and Chairman of the Commission for Ethical Questions, German Academy of Pediatrics, Frankfurt, Germany; 37Professor and Chairman of the Swedish Society of Pediatric Surgery, Sweden; 38Professor and Chairman of the Dutch Society of Pediatric Surgery, The Netherlands.

          Why is this different from a fallacious “appeal to authority” …? Because I was not citing the views of these distinguished doctors in lieu of giving a genuine argument; rather, I was pushing back against the claim that anti-circumcision advocacy is “anti-medical” and “pseudoscientific.” If you can argue, with a straight face, that the above panel of Europe’s most qualified pediatric authorities are “anti-medical” or dupes of pseudoscience, then be my guest. Their qualifications do not entail that their arguments against circumcision are correct, of course; nor does their being respected as scientific authorities by their peers show that their interpretations of the evidence are the only plausible interpretations; but these factors do indicate that opposition to circumcision is by no means confined to “anti-medical” or “pseudoscientific” corners, which is the only point I was making. I’m sure that you understood this, so I am truly puzzled by your accusation of fallacious appeal. I want to believe that you are engaged in this dispute in a spirit of fair-mindedness, but this makes it harder for me.

          I understand your concern about my linking to the cirkleaks page about Brian Morris. I hesitated before I did. My point in doing so was to show that he is not dispassionate on this issue, and of course I find much of his circumcision advocacy to be at such a level of unchained fanaticism as to make it very hard to take him seriously. Since you claim to be interested in reasoned discourse, careful evaluation of evidence, respectful dialogue, and so on, I think that you could do better than to rely on the work of Brian Morris to support your views. However, I do certainly agree with you that, as a general rule, it is better to address a person’s arguments directly than to “sling mud.” At the same time, let us not deny that a scientist’s personal history and extra-scientific motivations can, in some cases, justify raising a small flag of caution when approaching their body of work. By analogy, if Coca-Cola were to run a study on the benefits of drinking soda, we would have good reason to double-check their data.

          As a final thought, I’d say you’ve mischaracterized me by saying I’m a “representative of a movement” – I’m no such thing. I am a scholar interested in ethics; I am beholden only to myself, and I am interested in constructing meaningful arguments supported by the best evidence I can muster. Despite your hot rhetoric and evident frustration – and setting aside some of the obvious hypocrisy in what you’ve written (hypocrisy that I trust, in a calmer mood, you’d have filtered out in advance) – I will certainly do my best to consider your criticisms in the spirit you say you’ve intended. I strive to make arguments with integrity, and I am always open to fruitful dialogue. Thank you again for your time and consideration.

          Sincerely,
          Brian

          References:

          Chao, A., Bulterys, M., Musanganire, F., ABIMANA, P., Nawrocki, P., Taylor, E., … & Saah, A. (1994). Risk factors associated with prevalent HIV-1 infection among pregnant women in Rwanda. International Journal of Epidemiology, 23(2), 371-380.

          Dushoff, J., Patocs, A., & Shi, C. F. (2011). Modeling the population-level effects of male circumcision as an HIV-preventive measure: A gendered perspective. PloS one, 6(12), e28608.

          • Stephen Moreton says:

            Dear Mr Earp,

            I am impressed that you are still posting at 4:48 am, if the time indicated is correct. Unless you are in a different time zone. As you say this could drag on, and I certainly have not the time or stamina for it. You have indeed Googled me right and, as you say, “neither of us is particularly well-qualified to speak authoritatively about the medical evidence concerning neonatal circumcision and health benefits.” This is one big reason I do not advocate for infant circ. Although I sometimes point to the pro-arguments to show that the case is not as simple as some would have it. As I tend to approach ethics from a practical/utilitarian direction my inclination would be to settle the matter on the basis of a cost/benefit analysis, but right now the medics are having a big hissy fit about that. It may even be that infant circ would win such an analysis in some countries (e.g. where HIV is rampant) but not in others. I’ll leave it to the medics to battle out. Of course this does not stop intactivists. I note a response has appeared in this blog from “Doctors Opposing Circumcision”. But only one of the three names is a medical doctor. The others are a lawyer and a retired airline pilot! I wonder if they’d care to reveal how big their groups’ membership is, and what proportion are actually medical doctors?

            You may not consider yourself a “representative” of the anti-circ movement, but just by giving a talk repeating that movement’s common misleading claims (and they are misleading – as I have explained already), and putting it on the internet, you have effectively made yourself a representative of them. And the fact that a great flurry of responses appeared here very swiftly, including some high-profile anti-circ names, is downright suspicious and suggests to me that you are well-connected with the movement and have got your intactivist friends to weigh in.

            You deny your listing of 38 professionals opposed to circ was an appeal to authority. The appeal to authority applies not just when the authority is irrelevantly qualified (as with most creationists – glad you share my disdain for them, by the way) but also when there is no consensus amongst those that are. I could retort by listing the equally impressively credentialed AAP task force (and probably their Canadian counterparts who, I believe, are about to soften their stance too), the various researchers who have found benefits for circ, and (in the context of African AIDS) the WHO, UNAIDS & CDC. In the end it would just degenerate into a point-scoring competition to see who had the most names, but that is not how science is done.

            You do have valid points. There are issues of consent, probable variations in how men feel about their foreskins (mine, although medically fine, never gave me any pleasure), possibility of later resentment or feeling of loss and so on. I have long been aware of these points, and long accepted their validity. This is another reason I am reluctant to weigh in to the advocacy of infant circ. There are good arguments against as well as for, and you voice the former eloquently. All I am prepared to do is point to the counter-arguments to show it is not a clear-cut matter. And ask that you avoid the excesses of the anti-circ movement. The valid points you do make are good enough to stand on their own merits without recourse to passing off speculations as fact, citing unreliable sources like Van Howe, playing up the alleged negative effects of circ, downplaying its benefits, citing shoddy “studies”, routinely ignoring published critiques etc, etc. Why spoil good arguments by throwing in a load of crap?

            You were starting to do it in your last post, and doing it well. Acknowledging the limitations of the current data, the need for more, the weakness of anecdote … You even took on board my point about keratization. Great. But telling your audience things like the “truncation of the perineal nerve/erectile problems” argument, which are no more than untested speculations, is not on. And you still continue with comments about the foreskin’s alleged gliding and lubricating functions. I went over gliding earlier, and explained the lack of data about this, and whether it even matters. Gliding “property” might be a better way of referring to it, than “function”. I am also unconvinced about lubricating, but can’t be bothered debating it.

            Your acknowledgement that some men are happy about being circ’d is just a token nod, compared to the great list of untested speculations and sloppy studies implying that being circ’d is something dreadful. Please, next time reassure your audience that, although a significant number of men are unhappy with their circs (true), a majority of men circ’d as adults are happy with it. It does not mean that they cannot enjoy a terrific sex life, and for many there are no adverse consequences at all. That way you are not filling circ’d males with needless dread, and you can still make your valid points about the likely variability in foreskins and what their owners get out of them, and the advantage of waiting until they are old enough to determine if they’d like to dispense with their foreskin, or not. You can get those points across in a way that does not risk filling circ’d males with anxiety, and turning previously happily circ’d males into unhappily circ’d ones. It may not be your intention to do this, but please be aware that it is what you may be inadvertently doing.

            Incidentally, the observation that “the very large majority of intact men decline to undergo circumcision” does not hold everywhere, and is probably influenced by culture, circumstance and fear. I saw an informal survey somewhere (regrettably can’t remember where) that found that a good proportion of uncut American males wished they were circ’d, and there are proper studies looking at the acceptability of adult circ in relation to HIV prevention, and which found high levels of willingness. I guess if you see people all around you dying it has a sobering effect, but at least one of those studies was in China. Anecdotally (yes, I know) I had a chat with a young (uncut, heterosexual) colleague years ago who said he would not mind being circ’d provided it was done as a baby, and he rather wished he was, but he would be too scared to go through with it now. There are some men who’d cling on to their foreskins for dear life, some who’d like to be rid of them, but too scared, and (I suspect) a great many who couldn’t care.

            Not having time to continue further I will conclude with your own words: “One point on which I unreservedly agree with you is that all parties to this debate should take care to argue more thoughtfully, more humbly, and with greater concern for genuine engagement. Shouting matches are good for no one.” Absolutely, but I would add that they should also argue with more sensitivity to the feelings of circ’d males, and avoid making them feel they have suffered a grievous loss when they have not.

            And finally, I note the post here by Michael Glass. Having read his ten points I would like to award him ten out of ten.

            Sincerely,
            Stephen

            • Dear Dr. Moreton,

              At this point in our exchange of commentaries, I’m happy to say, I feel we’ve managed to identify some common ground. I certainly appreciate the more congenial tone to which we’ve migrated, and I thank you, once again, for taking the time to engage so thoughtfully and so passionately with the issues raised by my talk. I hope that those who read our back-and-forth will profit from the experience, whatever conclusions they end up drawing.

              There isn’t too much more for me go on about. We do still seem to disagree about the “appeal to authority” – so perhaps I should give that one more try. An appeal to authority is fallacious when one cites the views of “experts” on some matter in lieu of advancing an argument of one’s own, specifically as regards the point of contention in some dispute. I didn’t do this. Instead, I responded to the claim that you made—that anti-circumcision advocacy is “anti-medical” and “pseudoscientific”—by flagging the existence of a distinguished body of scientifically mainstream, well-respected doctors and physicians, that is, genuine world-leaders in the relevant fields of expertise, who have argued, on evidentiary as well as ethical grounds, that circumcision should not be performed in the neonatal period unless absolutely necessary. Here, importantly, the point of contention was NOT whether infant circumcision does indeed have net medical benefits, but rather whether the view that it does not have such benefits is “anti-medical” and/or pseudoscientific. Thus, all I needed to do to refute your claim was to demonstrate that anti-circumcision advocacy is not confined to quackery or to the mutterings of the scientifically illiterate. To do this, I appealed to the existence of a body of qualified, mainstream, scientifically and medically competent authorities whose evaluations of the relevant evidence align more closely with my conclusions than with yours (or those of the AAP, etc.). So, to clarify. The following would be an example of a fallacious appeal to authority:

              Stephen: I maintain that circumcision confers net health benefits. Brian: Well, a bunch of European authorities disagree with you. Since they are authorities and you are not, I win.

              On the other hand, the following would be a legitimate argumentative move:

              Stephen: Only anti-medical, pseudoscientific idiots think that circumcision does not confer net health benefits, causes harm, destroys function, etc. And anyone who thinks that the foreskin is erogenous tissue, serves a purpose in sex as well as in the protection of the glans, etc., is truly off their rocker. Brian: Well, it’s not quite true that the only people who maintain these positions are crack-pots and fanatics. Instead, some of the foremost authorities on these subjects, including distinguished physicians throughout Europe and Canada—i.e., those who are well-qualified to evaluate the relevant evidence—believe that circumcision is more risky/harmful than it is beneficial, that the foreskin is erogenous, that it serves sexual and protective functions, etc.

              Do you see the difference between those two cases? I hope so, as I’ve really tried to make the point. In any event, I wish you HAD taken the time to mention the background of the 8 members of the AAP committee charged with reviewing the evidence for and against the benefits of circumcision. You’d then have been obliged to bring to our attention the fact that 2 of the 8 members were Jewish (including the Chair of the committee) with one member, Dr. Andrew Freedman, boasting in an interview that he circumcised his own son on his parent’s kitchen table (contrary to the AAP’s code of bioethics prohibiting doctors from conducting surgery on family members) because he had “3,000 years of ancestors looking over [his] shoulder” (Merwin, 2012). You would think that a physician with a well-documented non-medical reason to endorse the genital cutting of infants might recuse himself from a committee charged with conducting a dispassionate analysis about the benefits and risks of such a surgery, but this did not occur in this case.

              Anyway, let me say what we can agree on. There are a large number of experts in pediatrics, epidemiology, medical ethics, etc., who think that circumcision is benign or beneficial, morally permissible and so on. I do not dispute this fact, and we could certainly count these experts in the “Dr. Moreton” column of our fictional point-scoring competition of dueling appeals to authority. I do think it is noteworthy, however, that these authorities are almost all American, albeit with a few exceptions (such as our Australian friend Dr. Brian Morris, who is actually a biologist and thus not an authority, by training, in any of the relevant fields of expertise). These authorities, furthermore, insofar as they are male, are typically (themselves) circumcised, and were so at birth, meaning that they are in a dangerously good position to fail to appreciate the potential value/functions of the foreskin, as well as the concomitant harms or disadvantages associated with cutting it off. That was the point of the European critique by Frisch et al., which, as I noted a few times before, I’ve discussed at length in another post.

              You write: “You do have valid points. … All I am prepared to do is point to the counter-arguments to show it is not a clear-cut matter. And ask that you avoid the excesses of the anti-circ movement.” I happily accept this critique. I would like to do a better job, as I dig deeper into this issue, and the long-standing debates associated with it, of acknowledging the gray areas with respect to the available evidence. I would also like to tailor my rhetoric more to the cause of engagement rather than polemics, and I expect that I have room for improvement in this area as well. Finally, I think you’re right that there is no need to go out of one’s way to make circumcised men feel somehow damaged/mutilated, and that it would be better to make arguments in this area with greater sensitivity to that fact. So I thank you again for your criticisms, as well as for your time and energy in engaging with me, and I hope we’ll both take up the cause of moving this debate into more productive territory. If you’re ever in Oxford, let’s meet for a beer sometime and talk about some of our non-foreskin related passions?

              With warm regards,

              Brian

              Reference

              Merwin, T. (2012, September 19). Fleshing out change in circumcision: An interview with Dr. Andrew Freedman. The Jewish Week. http://www.thejewishweek.com/features/new-york-minute/fleshing-out-change-circumcision

            • Dear Dr. Moreton,

              At this point in our exchange of commentaries, I’m happy to say, I feel we’ve managed to identify some common ground. I certainly appreciate the more congenial tone to which we’ve migrated, and I thank you, once again, for taking the time to engage so thoughtfully and so passionately with the issues raised by my talk. I hope that those who read our back-and-forth will profit from the experience, whatever conclusions they end up drawing.

              There isn’t too much more for me go on about. We do still seem to disagree about the “appeal to authority” – so perhaps I should give that one more try. An appeal to authority is fallacious when one cites the views of “experts” on some matter in lieu of advancing an argument of one’s own, specifically as regards the point of contention in some dispute. I didn’t do this. Instead, I responded to the claim that you made—that anti-circumcision advocacy is “anti-medical” and “pseudoscientific”—by flagging the existence of a distinguished body of scientifically mainstream, well-respected doctors and physicians, that is, genuine world-leaders in the relevant fields of expertise, who have argued, on evidentiary as well as ethical grounds, that circumcision should not be performed in the neonatal period unless absolutely necessary. Here, importantly, the point of contention was NOT whether infant circumcision does indeed have net medical benefits, but rather whether the view that it does not have such benefits is “anti-medical” and/or pseudoscientific. Thus, all I needed to do to refute your claim was to demonstrate that anti-circumcision advocacy is not confined to quackery or to the mutterings of the scientifically illiterate. To do this, I appealed to the existence of a body of qualified, mainstream, scientifically and medically competent authorities whose evaluations of the relevant evidence align more closely with my conclusions than with yours (or those of the AAP). So, to clarify. The following would be an example of a fallacious appeal to authority:

              Stephen: I maintain that circumcision confers net health benefits. Brian: Well, a bunch of European authorities disagree with you. Since they are authorities and you are not, I win.

              On the other hand, the following would be a legitimate argumentative move:

              Stephen: Only anti-medical, pseudoscientific idiots think that circumcision does not confer net health benefits, causes harm, destroys function, etc. And anyone who thinks that the foreskin is erogenous tissue, serves a purpose in sex as well as in the protection of the glans, etc., is truly off their rocker. Brian: Well, it’s not quite true that the only people who maintain these positions are crack-pots and fanatics. Instead, some of the foremost authorities on these subjects, including distinguished physicians throughout Europe and Canada—i.e., those who are well-qualified to evaluate the relevant evidence—believe that circumcision is more risky/harmful than it is beneficial, that the foreskin is erogenous, that it serves sexual and protective functions, etc.

              Do you see the difference between those two cases? I hope so, as I’ve really tried to make the point. In any event, I wish you HAD taken the time to mention the background of the 8 members of the AAP committee charged with reviewing the evidence for and against the benefits of circumcision. You’d then have been obliged to bring to our attention the fact that 2 of the 8 members were Jewish (including the Chair of the committee) with one member, Dr. Andrew Freedman, boasting in an interview that he circumcised his own son on his parent’s kitchen table (contrary to the AAP’s code of bioethics prohibiting doctors from conducting surgery on family members) because he had “3,000 years of ancestors looking over [his] shoulder” (Merwin, 2012). You would think that a physician with a well-documented non-medical reason to endorse the genital cutting of infants might recuse himself from a committee charged with conducting a dispassionate analysis about the benefits and risks of such a surgery, but this did not occur in this case.

              Anyway, let me say what we can agree on. There are a large number of experts in pediatrics, epidemiology, medical ethics, etc., who think that circumcision is benign or beneficial, morally permissible and so on. I do not dispute this fact, and we could certainly count these experts in the “Dr. Moreton” column of our fictional point-scoring competition of dueling appeals to authority. I do think it is noteworthy, however, that these authorities are almost all American, albeit with a few exceptions (such as our Australian friend Dr. Brian Morris, who is actually a biologist and thus not an authority, by training, in any of the relevant fields of expertise). These authorities, furthermore, insofar as they are male, are typically (themselves) circumcised, and were so at birth, meaning that they are in a dangerously good position to fail to appreciate the potential value/functions of the foreskin, as well as the concomitant harms or disadvantages associated with cutting it off. That was the point of the European critique by Frisch et al., which, as I noted a few times before, I’ve discussed at length in another post.

              You write: “You do have valid points. … All I am prepared to do is point to the counter-arguments to show it is not a clear-cut matter. And ask that you avoid the excesses of the anti-circ movement.” I happily accept this critique. I would like to do a better job, as I dig deeper into this issue, and the long-standing debates associated with it, of acknowledging the gray areas with respect to the available evidence. I would also like to tailor my rhetoric more to the cause of engagement rather than polemics, and I expect that I have room for improvement in this area as well. Finally, I think you’re right that there is no need to go out of one’s way to make circumcised men feel somehow damaged/mutilated, and that it would be better to make arguments in this area with greater sensitivity to that fact. So I thank you again for your criticisms, as well as for your time and energy in engaging with me, and I hope we’ll both take up the cause of moving this debate into more productive territory. If you’re ever in Oxford, let’s meet for a beer sometime and talk about some of our non-foreskin related passions?

              With warm regards,

              Brian

              Reference

              Merwin, T. (2012, September 19). Fleshing out change in circumcision: An interview with Dr. Andrew Freedman. The Jewish Week

        • Hugh7 says:

          It is hardly a Gish Gallop (a rapid succession of fallacious statements in a debate that leave an opponent no time to answer) to attempt to answer in print all the multifarious false claims one person makes. Circumcision is unique in the extraordinary number of false claims it attracts, as it is for the insane number and variety of reasons given for doing it.

          “whatever the pros & cons of snipping babies”
          * With a Gomco, Winkelman or Mogen Clamp it’s sliced – and a Mogen may take more than just the foreskin, which has led to successful claims worth millions and the Mogen company going out of business.
          * With a Plastibell or PrePex it’s crushed and allowed to die.
          * With an Accu-circ it’s chopped.
          – but never “snipped”.

          I have to congratulate Stephen Moreton for drilling down as far as a critique of Morris and Waskett’s critique of the Sorrells study, but he missed its main point – the same point that Morris and Waskett missed. The heart of their rebuttal of Sorrells et al. is that Sorrells et al. “fail to compare the same points on the circumcised and uncircumcised penis” – ignoring the fact that they do not have all of the same points, and this makes all the difference. Circumcised penises lack eight of the sites Sorrells tested – on the foreskin (and have two – on the scar – that intact men lack). Removing those sites from consideration, they found that circumcised penises are no less sensitive than intact ones. This is just what Masters and Johnson and several others have done, ignored the foreskin. It can hardly be surprising that penises with their foreskins ignored are very similar to penises with their foreskins removed. Sorrells et al.’s Figure 3 speaks for itself (especially when coloured: see the Intactivism Pages: /Sexuality.html#sorrells ).

          The AAP’s reply to the senior paediatricans’ charge of cultural bias is simply to say “tu quoque”, when a cultural bias towards infant genital cutting is a different kind of thing from the default position of leaving a child’s genitals, or its little toes, alone. No cultural bias is necessary in either case.

          Using the AAP Task Force’s own figures, the 38 critics showed that the it had utterly failed to demonstrate that “the benefits outweigh the risks”. It did not in fact weigh up the benefits against the risks, and it admitted that it had no figures for the most serious risks, of major complications and death, so it simply ignored them.

          Even before the 38 critics got there, the Task Force had admitted that it was not a normal foreskin that was the risk factor for penile cancer, but an abnormally narrow (phimotic) one, and a penis with a normal foreskin is at less risk of penile cancer than a circumcised penis. Yet it still says “Specific benefits identified included prevention of … penile cancer”.

          Morris’s attempts to distance himself from Quaintance (they must have collaborated quite closely on all those leaflets he wrote for Quaintance’s Gilgal Society) are just amusing, like his use of “bathroom splatter” and “zipper injury” to justify circumcision. In the last few days, and less amusingly, Morris goes further in a debate on the Daily UW, explicitly denying any connection with the Gilgal Society or Quaintance, when the connection is still clear on both his and the Gilgal websites. See the DailyUW The sex appeals: Length, curve, and circumcision” (about 3/4 down the page when all the comments are loaded)

          More serious is his blatant misuse of statistics. His claim that “Recurrent UTIs occur in 19% of uncircumcised boys, but in none of the circumcised.” (Morris, B, Why Circumcision is a biomedical imperative for the 21st Century, BioEssays 29:11, 1151) is one thing. The fact of the matter, 5 intact boys with recurrent UTIs out of 26 with any UTI and known to be intact (5/26=19%), out of 68 with any UTI, out of some 35,000 boys, ( http://circumstitions.com/Images/morris-conway.png ) is something quite different. (P.H.Conway, A. Cnaan, T. Zaoutis, B.V. Henry, R.W. Grundmeier, R. Keren, “Recurrent Urinary Tract Infections in Children, Risk Factors and Association With Prophylactic Antimicrobials,” JAMA, July 11, 2007, Vol 298, No. 2 – which would have been improved if it had left out its few words about circumcision).

          Suggestion: NEVER trust anything written by Morris.

        • Petit Poulet says:

          Dear Professor Moreton,

          There are several problems with your lines of reasoning. If making a reference to the rebuttal of the AAP Task Force by Frisch et al. is an example of the logical fallacy of an appeal to authority (argumentum ad verecundiam), then the use of any citations is a logical fallacy. There is nothing wrong with this. What may be worthy of debate is the strength and validity of the evidence. Do the authors have the training and credentials to be believable? Was the study designed properly and the data evaluated properly? Yet, as you comments demonstrate, how much weight and validity is assigned to a source of evidence can have a subjective element. In the case of infant circumcision, cultural values has a strong influence (Waldeck).

          Your knowledge of statistics appears to be limited to acknowledging that a study where n=1 does not have much power. Yes, there is variation between individuals, and we use statistics to determine how likely differences within a population based on certain traits can be explained by chance alone. For example, the fine-touch sensitivity of the glans penis in some circumcised men may be greater than the average sensitivity of men who are not circumcised, but this is does not negate that a finding that the average sensitivity of the glans in men who are not circumcised is statistically significantly greater than that in circumcised men. Also there may be men that have overall greater or lower overall penile sensitivity but the differences within the penis show a similar pattern.

          It is for this reason that the study by Sorrells et al. used a marginal mixed model, which allows multiple measurements on a single subject but controls for the location of the measurements. A marginal mixed model also treats each subject as his own stratum. This is a fairly advanced statistical procedure and not one found in basic, introductory biostatistics textbooks. This may explain why Waskett and Morris were so confused when they criticized the study by Sorrells et al.: they have had no formal training in biostatistics. In their criticism, these two circumcision fanatics prattled on and on about the individual comparisons they made using numbers presented in the table listing raw data and about their own special private interpretation of how to apply the Bonferroni correction, which is not how the correction was intended to be used. They completely ignored the primary results of study, which were obtained using marginal mixed models, which are more valid, powerful, and robust model than using isolated comparisons. The study was powered based on using marginal mixed models, which because they can incorporate multiple measurements from single subjects do not need as many study participants to be adequately powered. (A more primitive version of this model was used by Taddio et al. in their New England Journal of Medicine article on the effectiveness of EMLA for circumcision pain relief.) Their criticism made clear that they didn’t understand the statistics that were used in the study and that they have no idea of when or how to apply the Bonferroni correction.

          Two other studies have confirmed that the in the flaccid state, the glans of the circumcised penis is less sensitive to fine touch. In a study by Payne et al., one of the figures depicts this, but the manuscript does not give the data on which the figure was based and no statistics are given (their study was small and may have been underpowered). In a study by Bleustein et al., the decreased sensitivity of the circumcised glans was statistically significant when raw data was used, but was a non-significant trend when controlled for confounding factors. Likewise, the association between circumcision and meatal stenosis has been shown repeatedly in medical literature, with the rate ranging from 5% to 20%. Ignoring results that are repeatedly reported in the medical literature is unscientific.

          Errata also happen. It is important that once errors have been spotted, the correct data be published. In a meta-analysis of HIV risk in men having sex with men based on circumcision status published in JAMA by Millett et al. from the CDC, the 14% non-significant trend toward a lower risk of HIV infection in circumcised men that was originally reported was incorrect. When the calculations were done correctly, the difference was close to zero. JAMA printed a three-page erratum. Based on this does you suggest that anything the CDC publishes on circumcision be dismissed?

          Pooling of data from several studies is a common practice, but it can lead to Simpson paradox. This method of pooling data was used by Wiswell et al. when they published a meta-analysis of the studies looking at the association between circumcision and urinary tract infections, yet I don’t see you dismissing all that Wiswell has written on this topic. What is unfortunate is that studies that merely add up all the cases, without stratification get through the peer-review process without being noticed. Yet this is also what happened with the study on HPV infections published in the New England Journal of Medicine by Castellsagué et al. The failure of this study to stratify the data by the country they were collected lead to conclusions are likely to be invalid because the parametric statistical methods they used were unreliable because of the small number of men who were circumcised in four of the five countries, and the small number of men who were not circumcised in the fifth country. As a consequence, the high rates of HPV in Brazil, which also had a low circumcision rate, overwhelmed the data from the other countries.

          Similarly, their results could also be explained by sampling bias (they sampled the part of the penis (the glans) where men who have HPV and are not circumcised are more likely to shed the virus, but did not sample the part of the penis (the shaft) where men who have HPV and are circumcised are more likely to shed the virus). Multiple studies have found that location of HPV on the penis depends heavily on circumcision status. When it was demonstrated using meta-regression that studies that did not sample the shaft of the penis had a statistically significant greater negative association between HPV infection and circumcision, it is no great surprise that the authors of the New England Journal of Medicine objected. After all, this would suggest that their results were illusory and could be explained completely on the basis of sampling bias (this is also true of the HPV studies from the RCTs in Africa that only reported data taken from the glans of the penis). The tirade written by Castellsequé et al., trying to salvage their image, is almost comical as they demonstrate complete ignorance of the meta-regression and the numbers they provide in their rant confirm that incomplete sampling biases the results of the studies.

          Morris is not a statistician or a clinician. Waskett is not a statistician or clinician. Castellsequé is not a statistician. I would suggest that before you repeat libelous statements, that you determine whether these claims originated from people who have the qualifications, training, and expertise to be considered credible and within their field of knowledge. So when these individuals make accusations in an area in which they have little or no training or expertise and their comments that demonstrate their ignorance of biostatistics, you should pause before joining in lockstep with them.

          Relying on Morris is dangerous. A professor at a prestigious university was asked to peer-review a submission on which Morris was a co-author. He asked his graduate students to find copies of the 100+ citations given in the article to see if the statements in the article matched up to what was in the citation. They found that only a very small percentage of the statements were supported by the citations given. You can do this with any of Morris’s publications and you will find that about 10% to 20% of his statements are factually accurate and not incomplete, misleading, or fabricated. Morris believes that when he gets an attack letter published, that his claims, no matter how unsupported, within the letter are valid. In subsequent publications, he will repeat these scientifically unsupported claims and cite his attack letters as references. He is delusional to the point that he believes that his fabrication are facts. The problem is that medical journals cannot afford fact checkers. The editors expect the submitting authors to be honest and honorable. Unfortunately, the peer-review process gets hijacked when similarly minded advocates are enlisted to review and rubber-stamp inaccurate, unscientific manuscripts. So, caveat emptor. Check the citations. See if they are opinion pieces, letters to the editor, or accurately reflect what is stated. Do your homework, before making claims that you cannot support without relying on an appeal to authority, especially when the authorities you appeal to do not have the credentials to be authorities.

    • Stephen Moreton says:

      Excuse a typo in my post. “APA” should read “AAP”.

      • Ron Low says:

        Dr. Moretown is entitled to his opinion about whether a foreskin contributes to sexual sensation, and SO IS every foreskin owner. HIS body, HIS decision.

    • Ladyfingers says:

      You’re citing “studies” by Morris, Bailey and Waskett? Please.

    • Paul Mason says:

      A hallmark of genuine propaganda is the setting up of straw men. So one starts one diatribe by asking one’s audience to assume a false premiss, in this case “to…turn the listener against ALL infant circumcision.” and “calculated to make circumcised males feel bad”, “The foreskin is NOT erogenous”.

      Well maybe the paper did have the effect of making Moreton “feel bad” and heap invective on abuse in addition to citations from devout advocates and propagandists like the B Morris he cites, but there is no hint in Earp’s paper that it was “calculated to make readers feel bad” nor to “turn the listener” against medically indicated genital surgery. Becuase of his PhD, Stephen will know that counter-example undermines the proof. Morris is admittedly circumcised and speculates about the sensation and phenomenology of having a foreskin the way I might about the sensation of having labia minora.

      The Schober study does not say that foreskin “is not erogenous”: if our learned PhD had read the he would see that foreskin was not listed in the “Domains and Areas” investigated. Absent. Not there. No basis for that straw man of Stephen’s. I have a foreskin and it has sensation in it. Cut if off and cut off that sensation. Simple.

      No mention in Schober of frenulum either, when the big secret for men and women with intact frenulum or clitoris is that they figure large in getting your jollies, though studies show that orgasm is achievable if you have chopped it in half or transformed it into scar tissue.

      The whole point is that “the best” time to do unnecessary circumcision is not when it is “Clinically easiest”, as clinical ease does not equate to “goodness” outside the confines of clinical practice. Which leaves us with Earp: ethically, the “best” time to perform any unnecessary genital surgery is when you are old enough to choose it for yourself.

      I deduce that, like many men who defend its unnecessary amputation and defend their lifelong identification with their own male member as subjectively normal, Stephen does not have a foreskin. He will splutter “What evidence do you have of that” but we all know it’s true as a matter of common knoweldge from reading his response.

      I hold that in this debate we each have the potential for conflict if interest in arguing for unnecessary surgery on children if we are cut ourselves and regard the uncut penis as “normal” despite the global statistics. In other Stephen failed to disclose his conflict. Which is unethical.

      I wonder in fact – from the hysterical and unscientific resort to hyperbole and value expressions as well as from citing multiple Morris articles – if “Stephen Moreton PhD” is not yet another avatar for the infamous Morris. Hi Brain!

    • sean says:

      Stephen Moreton Ph.D. what is yor doctorate in? Stupidity?

  • Ronald Goldman, Ph.D. says:

    There is plenty of evidence and common sense to support the position that circumcision diminishes sexual sensitivity and function. How could missing about twelve square inches of erogenous tissue not make a difference!? A study showed that circumcised men are 4.5 times more likely to use ED drugs.

    Let’s understand that there are millions of dollars that reward circumcision advocates, researchers, and supporting corporations. This is called financial conflict of interest. The HIV studies only prove that advocates can find what they are looking for, more health “benefits” of circumcision. This pattern of seeking health “benefits” is over 130 years old! All the historical claims have been refuted. There are also personal, cultural, and political conflicts of interest for advocates. See Circumcision Policy: A Psychosocial Perspective.

    Circumcision critics often work as volunteers with no conflicts of interest.

    There is much evidence that circumcision is traumatic. Psychologists know that there is a compulsion to repeat trauma. Flawed “research” is used to provide the “science” behind repeating the trauma of circumcision. It’s clear that circumcised doctors and researchers want to push circumcision on the whole world.

    Let’s find the courage to admit our mistake and spare the next generation from this specious and harmful genital surgery.

    Fine-Touch Pressure Thresholds in the Adult Penis
    http://www.ncbi.nlm.nih.gov/pubmed/17378847
    http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2006.06685.x/full

    The Prepuce
    http://onlinelibrary.wiley.com/doi/10.1046/j.1464-410x.1999.0830s1034.x/pdf

    Male Circumcision and Sexual Function in Men and Women: A Survey-Based, Cross-Sectional Study in Denmark
    http://www.ncbi.nlm.nih.gov/pubmed/21672947

    The Psychological Impact of Circumcision
    http://onlinelibrary.wiley.com/doi/10.1046/j.1464-410x.1999.0830s1093.x/pdf

    Physical, Sexual, and Psychological Effects of Male Infant Circumcision
    http://epublications.bond.edu.au/greg_boyle/14/

    Alexithymia and Circumcision Trauma: A Preliminary Investigation
    http://www.mensstudies.com/content/2772r13175400432/?p=a7068101fbdd48819f10dd04dc1e19fb&pi=4

    Male Circumcision: Pain, Trauma and Psychosexual Sequelae
    http://www.cirp.org/library/psych/boyle6/

    The Effect of Male Circumcision on the Sexual Enjoyment of the Female Partner
    http://onlinelibrary.wiley.com/doi/10.1046/j.1464-410x.1999.0830s1079.x/pdf

    Circumcision Policy: A Psychosocial Perspective
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2724127/?tool=pubmed

    Doctors Opposing Circumcision Medical Ethics Report
    http://www.doctorsopposingcircumcision.org/info/info-medicalethics.html

    Doctors Opposing Circumcision Human Rights Report
    http://www.doctorsopposingcircumcision.org/info/info-humanrights2006.html

    Involuntary Circumcision: The Legal Issues
    http://onlinelibrary.wiley.com/doi/10.1046/j.1464-410x.1999.0830s1063.x/pdf

    Informed Consent for Neonatal Circumcision: An Ethical and Legal Conundrum
    http://www.cirp.org/library/legal/conundrum/

    Male Circumcision and HIV Prevention: Insufficient Evidence and Neglected External Validity
    http://www.davidwilton.com/files/ajpmgreenetal2010-pub1.pdf

    How the Circumcision Solution in Africa Will Increase HIV Infections
    http://www.publichealthinafrica.org/index.php/jphia/article/view/jphia.2011.e4

    Male Circumcision is Not the HIV “Vaccine” We Have Been Waiting For!
    http://www.futuremedicine.com/doi/full/10.2217/17469600.2.3.193?prevSearch=authorsfield%253A%2528Green%252C%2BLawrence%2BW%2529&searchHistoryKey=

    The Cost to Circumcise Africa
    http://www.icgi.org/Downloads/IAS/McAllister.pdf

    Doctors Opposing Circumcision HIV Statement
    http://www.doctorsopposingcircumcision.org/info/HIVStatement.html

    Political Determinants of Variable Aetiology Resonance: Explaining the African AIDS Epidemics
    http://ijsa.rsmjournals.com/content/20/12/834.abstract

    Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision http://pediatrics.aappublications.org/content/early/2013/03/12/peds.2012-2896.full.pdf+html

  • Robert Darby says:

    Dr Moreton PhD attempts a reasoned critique of Brian Earp’s arguments, but most of his references are either out of date or copied from the usual pro-circumcision stable, whose arguments are just as emotional, selective and untrustworthy as anything from the so-called “anti-circumcision movement” – an entity that exists only in the minds of the “pro-circumcision movement”. All Moreton is doing is repeating the old health benefits line, studiously ignoring the fact that it has been subjected to a stream of devastating critiques from Wallerstein (1978) until the present, and presumably on the principle that if you repeat something often enough people will come to believe that it is true. He also fails to distinguish between circumcision elected for themselves by competent adults and circumcision imposed upon non-consenting minors, and totally ignores all the ethical, human rights and legal arguments that have been so prominent in recent times.

    Even if it were true that circumcision conferred the protections that he claims (an equivocal point at best, asserted only by circumcision promoters and weakly by the AAP – so weakly that it does not recommend circumcision as a routine), and even if it were also true that the protective effect was greater if circumcision is performed in infancy (a claim for which there is no evidence at all), non-therapeutic circumcision of minors would still not be justifiable because it ignores the fundamental issues – the preferences of the individual and the harm of foreskin loss. It would also violate Beauchamp and Childress 5 principles of medical ethics (autonomy, beneficence, non-maleficence, proportionality and justice), the child’s right to an open future, accepted human rights principles, such as bodily integrity, and may also be unlawful – as I argued in my submission to the Tasmania Law Reform Institute inquiry:

    http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2276538

    and as Peter Adler argues with reference to the United States:

    Adler PW. Is circumcision legal. 16 Rich. J.L. & Pub. Int. 2013;16: 439. Available at http://rjolpi.richmond.edu/archive/Adler_Formatted.pdf

    As for Moreton’s statement that the foreskin is not erogenous tissue: for goodness sake, how out of touch with reality can you get?! You don’t need elaborate studies published in peer reviewed journals to prove the contrary (though many such studies exist); all you need to do is to ask the average (uncut) teenager or take advantage of the abundant supply of free, on-line porno to watch the differing masturbation techniques of circumcised and uncircumcised men. For all his condemnation of Brian Earp as emotionally driven, Moreton is no less rhetorical and emotional: according to him, those wicked anti-circumcision fanatics are also anti-vaccination and causing deaths in Africa. I am not aware of any published critiques of NTC in which the author condemns vaccination as well, and many such papers explicitly endorse and approve of vaccination as a modern, scientific means of reducing the risk of disease (unlike circumcision) – for example:

    Robert Darby and Robert Van Howe, “Not a surgical vaccine: There is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia.” Australian And New Zealand Journal of Public Health, Vol. 35, October 2011: 459-465. Available at http://onlinelibrary.wiley.com/doi/10.1111/j.1753-6405.2011.00761.x/full

    There are even anti-circumcision websites that endorse vaccination:

    http://www.circinfo.org/news_2013.html#hpv

    For all his references to science and objectivity, Dr Moreton’s tone is not that of a modern, scientifically informed and ethically aware observer, but of a moralising Victorian medical man who believes that if a doctor thinks something is good for you, it is your duty to submit to it whether you like it or not. It is time he realised that the age of the God-doctor is long past.

  • Patrick Smyth says:

    Stephen Moreton suffers from the parallax view that many defenders of the infant circumcision status quo are prone to do. Both he and Brian Earp can quote supposedly authoritative and reliable studies at each other in support of their own case till the cows come home, but there is still no escaping the fact that a normal functional healthy body part is being regularly amputated from infant boys in this world and those boys are being given no opportunity to raise an objection until it is too late and the damage is done. He says “Otherwise his piece is highly misleading, and calculated to make circumcised males feel bad. This is a great recruitment ploy, but is misleading and unethical. Done properly, circumcision makes no difference to sexual function.” Wow! Stephen Moreton is either totally myopic or has an aversion to the practice of masturbation. I only have to log on to pornhub and I can find countless examples of intact penises that have much more sexual function than my own penis that my mother kindly had the foreskin removed from! I struggled to masturbate with my surgically modified penis as an adolescent and regularly got friction burns and blisters because there was insufficient mobile skin left. That is a significant difference in sexual function in my book! Is Stephen Moreton so ill-informed that he is unaware that circumcision was widely promoted in the last century as a means to inhibit the ability of a male to masturbate? I lived in ignorance for many years of this aspect of the sordid history of circumcision, and was finally awakened from my ignorant state by a video of an intact male masturbating, with great ease and was instantly enraged that this simple natural pleasure had been denied me by my mother. I did not need to read an article by Brian Earp to make me feel bad. I could instantly see that my body had been subjected to a profoundly unethical interference. I shall leave you with a quote from Jackin World: “If you were never circumcised, and therefore you have some extra skin on your penis to move up and down along the shaft, you can simply grab on firmly and pump away, rolling the sleeve of skin that covers your penis back and forth over the shaft. This will cause your “foreskin” (that’s the skin that surrounds the penis head) to move back and forth across your penis head, producing a great feeling.” (http://www.jackinworld.com/techniques/the-basics).

  • Chip Smith says:

    I don’t detect a note of “propaganda” in Brian Earp’s qualified account of the evidence for the detrimental effects of infant circumcision, nor in his rehearsal of moral arguments that attend the scientific controversy. My propaganda alarm is tripped, however, when I encounter a rejoinder that equates circumcision with vaccination, implying that ethical arguments against involuntary circumcision are analogous to anti-vaccination pseudoscience. The analogy is preposterous, but it can be readily understood as a “scare tactic” intended to cast a pall over any discussion that follows.

  • Hugh7 says:

    “The foreskin is NOT erogenous. ”
    Sorry, too many men who actually have one will tell you you are wrong. The Schober study dances around the elephant in the room. It had only 11 intact men (N=81), and its bias is evident from the fact that it is written as if circumcision is not genital surgery. Strikingly, the (circumcised) men ranked the frenulum, the last remnant of Taylor’s ridged band of the foreskin, highest for sexual pleasure.
    (See the Intactivism Pages, /Sexuality.html#schober)
    For centuries before non-religious circumcision became customary, it was well known that the foreskin gives pleasure, and this was one important reason given for performing circumcision: (See the Intactivism Pages /Pleasure.html)

    “There are actually more of these nerves, per square cm, in the feet than in the foreskin, and they are bigger too. Are feet erogenous?”
    Well, for many people they certainly are, and for some, extremely so. (The Chinese custom of foot-binding, as a human rights issue a close analogue of circumcision, was very much about the erogenous nature of the female foot.) But when you look at the structure, positioning and unique rolling action of the foreskin, how could it, placed where it is, NOT be erogenous?

    The Meissner’s corpuscles in the foreskin are concentrated in a ridged band running round inside the tip. (Taylor, J.P., A.P. Lockwood and A.J.Taylor The prepuce: Specialized mucosa of the penis and its loss to circumcision Journal of Urology (1996), 77, 291-295) Who knows from where on the foreskin Bhat et al. took their sample? Their names indicate they have no first-hand experience of the foreskin, and may well have a religious prejudice towards circumcising.

    Dr Moreton has the advantage of reading the Tian et al. study, which is still in the press. Frisch et al. (Frisch M, Lindholm M, Grønbæk M.Int J Epidemiol. 2011 Jun 14 Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark) found a clear correlation between circumcision and sexual difficulties in both men and their partners.

    Szabo and Short’s conclusion is based on “Histological observations … on samples of penile tissue obtained from 13 perfusion fixed cadavers of men aged 60-96 years, seven of whom had been circumcised.” The advanced age of the men from whom these few samples were taken, in considering a process that is age-related, throws suspicion on this work.

    The O’Haras say that when the respondents recruited from anti-circumcision sources are removed, their results are unchanged. Perhaps more interesting is the qualitative data: “Respondents overwhelmingly concurred that the mechanics of coitus was different for the two groups of men. Of the women, 73% reported that circumcised men tend to thrust harder and deeper, using elongated strokes, while unaltered men by comparison tended to thrust more gently, to have shorter thrusts, and tended to be in contact with the mons pubis and clitoris more, according to 71% of the respondents.” This accords with the supposition that circumcised men, receiving fewer stimuli, must thrust harder to achieve the same effect – or rather “to reach orgasm” as they are fond of putting it. The pleasures of the journey seem to be lost on them.

    “Any argument about risks has to be balanced by the risks of NOT circumcising.” Actually, they are risks of other things. The foreskin is only a place that they can happen. Having complete genitals does not directly cause any harm. If it did, the foreskin would have evolved away aeons ago. The AAP failed to do any risk/benefit analysis. Their critics did, using the AAP’s own figures, and found the case for circumcision lacking. The AAP could find no statistics for major complications or death, so it simply ignored them.

    “One does not even have to go further than good old Wikipedia to spot the cherry-picking here.” Very true: for years the Wikipedia entries on circumcision were ruthlessly culled by someone who chose to have himself circumcised in adulthood, who made more than 10,000 edits on the topic.

    You could say the 38 top paediatricians, heads and spokespeople for 22 paediatric associations in Austria, Britain, Denmark, England, Estonia, Finland, Germany, Iceland, Latvia, Lithuania, Norway, Sweden, and the Netherlands and senior paediatricians in Canada, the Czech Republic, France and Poland (pediatrics . aappublications . org / content / early / 2013 / 03 / 12 / peds.2012-2896.full.p d f+h t m l) have a cultural bias against circumcision, just as they have a cultural bias against cutting off neonates’ earlobes. Yet not one of them has a “Task Force on Leaving Babies’ Genitals Alone (or Earlobes)” as the AAP has a “Task Force on Circumcision”. Leaving babies’ genitals alone, not performing non-essential surgery on them, is the default position. It requires no justification. Only cutting parts off needs to be justified.

    “There is no evidence that infant circumcision is effective against HIV” is a simple statement of fact. Many studies contrasting neonatally-circumcised men with intact men have failed to find any significatnt difference in HIV acquistion.
    “If adult circ protects, why not infant circ?” This is not a valid argument. It’s a big “if”. There is much evidence that the apparent protective effect of adult circumcision comes from aspects of the operation itself – experimenter and experimentee effects, changes in behaviour, and the Hawthorne Effect, that just being in a study changes things. These will not apply to infant circumcision.

    Most of Dr Moreton’s references are to studies by the small group of interlinked researchers responsible for the flurry of recent pro-circumcision research – Robert Bailey, Stefan Bailis, Ronald Gray, Daniel Halperin, Godfrey Kigozi, Jeffrey Klausner, Brian Morris, Stephen Moses, Malcolm Potts, Thomas Quinn, David Serwadda, Dirk Taljaard, Aaron Tobian, Maria Wawer, Jake Waskett, Helen Weiss. They spend all their time (and make their living) by promoting circumcision. Some have indicated mixed and unscientific motives (Halperin thinks he was “destined” to promote circumcision.). The Wawer-Gray study of age of circumcision is interesting in finding that “Circumcision after age 20 years is not significantly protective against HIV-1 infection.” A curious finding that warrants further study, surely? Or just another example of a constant theme in pro-circumcision literature: “Hurry, buy now! This offer won’t last!”

    “…calculated to make circumcised males feel bad…making them feel they are damaged goods”.
    If circumcised men feel bad when they learn what they have lost, that is appropriate, but “calculated”? Dr Moreton seems to be speaking from the heart – or perhaps further down.

  • James David says:

    I would give a years salary to get my foreskin back.

  • John Geisheker, JD, LL.M says:

    THE MORBIDITY OF CIRCUMCISION IS ENTIRELY UNKNOWN

    Mr. Moreton’s pro-cutting infomercial for circumcision shows more faith in the medical system he defends than is warranted. Moreover, male circumcision is mostly about atavistic and superstitious impulses which pre-date evidence-based medicine.
    Our international physicians’ non-profit is keenly aware of the poisonous roots of the male circumcision tradition. The origins of this pre-germ-theory, pre-anesthesia, pre-human rights, pre-bioethics practice are well documented.[1]
    Much less available is any credible and honest data about short or long-term morbidity (physical or psychological), especially not in the USA, the last country to cling to it, wholly for financial reasons.
    Most everything on offer has been penned by emotion-driven apologists for the practice, often those with ties to, or influenced by, religions that condone the practice, and/or those who profit by it. The literature on offer, fully evident in the footnotes Mr. Moreton references, reeks of conflict of interest and emotional obsession.[2]
    There is also no history in male circumcision, even today, of effective anesthesia or analgesia, the withholding of which is the very hallmark of a deeply imbedded, merely cultural, genital mutilation, no different in applied bioethics from female circumcision found in East Africa or the Middle East.
    Consider the fact that US medical residents, med students, OB’s, nurses, and midwives, may legally circumcise a male child without the slightest urological training, save for the hoary, folkloric, “watch one, do one, teach one.” Religious officials can do so without so without so much as a first-aid course. Parents may freely circumcise their children with clamps available on eBay for US$10. And everyone can escape legal consequences if they mouth the words, “God / parents / conformity told me to do it.”
    No one is legally required —anywhere— to screen for blood disorders, use a clinical setting, or provide anesthesia, a crash cart, or a back-up team which could manage a ‘code blue.’ No one need do anything more than profit by the disgraceful lack of child rights, lax legal and clinical standards, and familiarity ––abetted by touts like Mr. Moreton.
    (Moreton bizarrely claims that the foreskin is not erogenous, although the foreskin’s erogenous qualities have been known to every man with a foreskin since before the Renaissance, and the foreskin has been identified in histology as a “specific erogenous zone” since at least 1959.[3] Only a male who lacks a foreskin could have made such an absurd statement. We know that circumcised men need to justify to themselves their loss of erogenous sensation and sexual pleasure, and this alone accounts for the outrageous claims of circumcision touts.) [4]
    Circumcision of male children is entirely unregulated, and the resulting injuries are entirely unknown. When ‘accidents’ occur they are deeply disguised.[5] What literature we have flows from Anglophone circumcisers (themselves circumcised, of course) who, as can be guessed, have reasons to promote the procedure and to deny any morbidity whatsoever. This is no different from East African midwives, themselves circumcised, who profit by continuing the practice on female children in their villages, and deny any downstream problems. “The cut,” as the expression goes, “become the cutters.”
    Even the American Academy of Pediatrics agrees circumcision morbidity is unknown. In their September, 2012, statement, they freely admit: “The true incidence of complications after newborn circumcision is unknown…,” and later, “There are no adequate analytic studies of late complications in boys undergoing circumcision in the post newborn period,” [6] which translated means, “we simply do not know,” (and, more to the point, do not care to look). This is a very good reason to be cautious and not to make claims the practice is benign or wholesome or pain-free or necessary or prophylactic.

    And that is also the reason why thirty-eight leading European specialists recently took the American Academy of Pediatrics to task.[7] The ethical steady-state of medicine is not to amputate healthy tissue from healthy non-consenting child-patients, a practice condemned by international medical ethics.
    The steady-state, default position of medicine demands we understand that the humans are highly evolved, and we cut off healthy, functional, highly nerve supplied, protective, immune-active parts of their bodies at peril to our patients –and ourselves.
    George C. Denniston, MD, MPH
    John V. Geisheker, JD, LL.M.
    George Hill
    Doctors Opposing Circumcision
    Seattle

    1. Glick, Leonard. Marked in Your Flesh: Circumcision from Ancient Judea to Modern America. New York: Oxford University Press, 2005:242.

    2. Hill G. The case against circumcision. J Mens Health Gend 2007;4(3):318-23.

    3. Winkelmann RK. The erogenous zones: their nerve supply and significance. Mayo Clin Proc 1959;34(2):39-47.

    4. Goldman R. The psychological impact of circumcision. BJU Int 1999;83 Suppl. 1:93-103.

    5. The full sweep of non-regulation is detailed in: The completely unregulated practice of male circumcision: human rights’ abuse enshrined in law? New Male Studies, 2, 18-45 (2013).

    6. Task Force on Circumcision. Technical Report: Male Circumcision. Pediatrics 2012;130(3):e756-e785.

    7. Frisch M, Aigrain Y, Barauskas V, et al. Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision. Pediatrics 2013; 131:4 796-800; published ahead of print March 18, 2013, doi:10.1542/peds.2012-2896.

  • Michael Glass says:

    John Geisheker and Stephen Moreton have sharply differing opinions on circumcision but both have called for greater regulation of the practice. I agree. Here is what I think should be changed:

    1 The forced circumcision of men should be made a criminal offence, and I believe that forced circumcision should be treated as sexual assault.
    2 Only qualified people should be allowed to circumcise anyone. Any unqualified operator should be prosecuted.
    3 No person should be circumcised without appropriate pain relief, adequate hygiene and proper back-up in case of haemorrhage or other emergency.
    4 No circumcision for medical reasons shall be performed without due cause, and not until more conservative treatments have been tried without success.
    5 No adult or older child circumcision should be performed without the written agreement of the person to be circumcised.
    6 No child should be circumcised if he objects to the procedure and no baby should be circumcised without the written agreement of both parents.
    7 Before anyone is circumcised, the written warranty of an independent physician should state that the patient is stable, healthy enough to withstand the surgery and free of all bleeding defects or genital anomalies that would make the procedure inadvisable.
    8 After the circumcision the patient should be reexamined by an independent physician.
    9 The result of this examination should be kept for 7 years or until the patient turns 21.
    10 The circumciser shall be held legally and financially responsible for any complications or any mistakes in surgery.

    These rules would not eliminate all bad outcomes but they would help to minimise any problems that could arise. If problems should arise, the responsibility should fall on the circumciser.

    • Hugh7 says:

      This is a start, but the central ethical problem remains. In order to ethically reach point 5, no baby or child should be circumcised without pressing medical need.

      • Michael Glass says:

        This is is an ethical position that is unachievable at the moment. Look at what happened in Germany. To get to a point where infant and childhood circumcision would be prohibited it would need a change of heart from Muslims, Jews, Americans and many of the circumcising tribes and groups throughout the world. That’s a pretty big ask, but let’s look at the changes that have been achieved by consistent effort.

        *Slavery has been abolished.
        *Chinese foot binding has become a thing of the past.
        *The Indian custom of burning widows on their husbands’ funeral pyres has largely been suppressed.
        *Europeans have stopped slaughtering people accused of witchcraft.
        *Corporal punishment of children is more and more discouraged.
        *Christians have largely changed their minds about contraception and divorce and remarriage.
        *Muslims are changing their minds about female genital mutilation.

        It took hundreds of years to abolish the burning of witches. It took a lifetime to abolish slavery in the British Empire. Attitudes on divorce, contraception and the remarriage of divorcees took over a century. A reexamination of infant and childhood circumcision will take a long time. In the mean time, the changes that I have proposed could make a difference to child welfare and lead to further changes down the track..

  • Marilyn Milos, RN says:

    Brian, your calm manner, reasoned arguments, ability to state the facts accurately and the truth without being offensive, and your amazing patience are to be commended! Well done. You are indeed a philosopher, an ethicist, and a gentleman.

  • Brother K says:

    When you criticize a man for the peculiarity or irrationality of his thought process, that is not ad hominen argumentation but rather an appeal to the man’s character and integrity (if he has any). The problem with a circumcised man defending and/or promoting baby circumcision is that there’s always the specter of his own anxiety hovering in the background. Anxiety is not a pleasant feeling, and people will move mountains (and foreskins) to avoid it.

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