Brian D. Earp believes circumcision is worth talking about. And he would like Mr. Stern and the editors of Slate magazine to know why.
Dear Mr. Stern,
I recently read your article, “How Circumcision Broke the Internet” for Slate magazine [republished as "'Intactivists' Against Circumcision" in Canada's National Post]. I understand your concern about overheated rhetoric in public debates as well as the misuse of science to support untenable positions. As a scientist and ethicist who studies circumcision professionally, I will admit that I have seen this happen on both sides of this particular controversy. I think, however, that in your hurry to admonish “the intactivists” for pushing their anti-circumcision arguments too far, you may have fallen prey to some of that very same rhetorical excess (as well as misuse of science) in your own piece.
First, when you said that circumcision used to be “practiced by most families” I’m glad that you added the qualifier, “in America at least.” This is an important point. Circumcision is extremely uncommon in most parts of the world, and about 70-80% of men globally are left intact. Over 70% of those who are circumcised come from the Muslim world where it is done as a rite of passage; it is also a rite of passage in countries like South Africa, where at least 39 young men recently died from complications related to circumcision, such as excessive bleeding from their penises. Europeans, by contrast, (including the British; as well Latin Americans, Canadians, Australians, New Zealanders, the Japanese, the Chinese, Russians, and Indians–that is, most of the developed world) very rarely circumcise outside of religious communities (if at all). A majority of doctors from these countries insist that any “health benefits” conferred by circumcision–even when the procedure is performed correctly–are dubious at best. In fact, 37 of Europe’s most pre-eminent medical authorities (along with the distinguished Canadian pediatrician, Dr. Noni MacDonald) have recently expounded on this point in the flagship journal Pediatrics:
Only one of the arguments put forward by the American Academy of Pediatrics [concerning potential health benefits for 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.
Also, I noticed that you cite a “systematic review” by Brian Morris (and a co-author) in support of one of your claims about penile sensitivity. Your readers may not be aware that Professor Morris runs a pro-circumcision advocacy website, has founded a highly active circumcision lobby group (some of whose board members derive a substantial income from performing circumcisions), and has recently been profiled in the International Journal of Epidemiology as being engaged in systematically distorting the academic literature on circumcision:
[As] in critical letters to the editor following other recent studies that failed to support their agenda, Morris et al. air a series of harsh criticisms against our study. As seen, however, the points raised are not well founded. It seems that the main purpose, as with prior letters, is to be able in future writings to refer to our study as an “outlier study” or one that has been “debunked”, “rejected by credible researchers” or “shown wrong in subsequent proper statistical analysis.” … As these critics repeatedly refer to Morris’ pro-circumcision manifesto as their source of knowledge, their objectivity must be questioned.
Perhaps it is not much of a surprise, then, that Professor Morris’ “systematic reviews” tend to yield results that come out rather favorable toward circumcision: indeed, he has invested a considerable amount of energy in making sure that they do. In other words, it isn’t quite enough to simply dredge up a reference in support of your argument — anyone with a computer and access to the internet can do that. Instead, researchers who study circumcision more seriously have to consider that even the most basic science on the subject is as complex as it is contentious. For example, this recent analysis criticizes the methodology of the “sexual satisfaction” findings from the African studies you mentioned:
Rather than blindly accepting such findings as any more trustworthy than other findings in the literature, it should be recalled that a strong study design, such as a randomized controlled trial, does not offset the need for high-quality questionnaires. Having obtained the questionnaires from the authors (RH Gray and RC Bailey, personal communication), I am not surprised that these studies provided little evidence of a link between circumcision and various sexual difficulties. Several questions were too vague to capture possible differences between circumcised and not-yet circumcised participants (e.g. lack of a clear distinction between intercourse and masturbation-related sexual problems and no distinction between premature ejaculation and trouble or inability to reach orgasm). Thus, non-differential misclassification of sexual outcomes in these African trials probably favoured the null hypothesis of no difference, whether an association was truly present or not.
Speaking of those African trials, you write that “circumcision lowers the risk of HIV acquisition in heterosexual men by about 60 to 70 percent.” But you left out a few important qualifiers. First, the participants in those studies were adult volunteers, not infants. Second, the studies themselves have been criticized in the academic literature for being scientifically flawed, with problems pertaining both to internal and external validity. Among other issues, not one of the studies was placebo-controlled (which would be impossible to achieve in this case, but which calls for caution in interpreting the results); and all three of the trials were stopped early, which typically has the effect of overestimating the effect size of the “treatment” being studied. They also find an absolute risk-reduction of only 1.3% between the treatment and control groups, which is somewhat less impressive-sounding than the relative risk-reduction of 60% that is normally reported in the media. Of course, the studies have also been vociferously defended, by none other than our good friend Brian Morris (see above) along with his usual team of collaborators including the software engineer and “internationally recognized circumcision activist“ Jake Waskett. Readers will, of course, have to evaluate both the scientific criticisms and the defenses of the original trials to get a sense of the debate in this area, and draw their own conclusions.
But let us assume that the findings from the African trials are valid. Even so, they would not apply to “heterosexual men” (as you stated) tout court. First, the studies were carried out in Kenya, Uganda, and South Africa, each of which has a very different epidemiological environment and disease profile than what is seen in countries such as the United States. For example, in Kenya, Uganda, and South Africa, the base rate of HIV transmission is very high, and the virus is spread primarily through heterosexual contact. In places like the the U.S., by contrast, the base rate of HIV transmission is very low, and the virus is spread primarily through injective drug use and gay sex. Accordingly, even if we were to accept the findings from the African trials at face value, we would have no evidence that circumcision could be useful in other parts of the world, let alone in infants, who are not susceptible to contracting HIV (unless they are molested).
Meanwhile, females in Sub-Saharan Africa may actually be at an increased risk of HIV infection as a function of male circumcision, raising concerns about deleterious population-level effects on women.
The fact that the African trials were carried out on adult volunteers is significant. For one thing, adult circumcision is likely to have differential down-stream behavioral effects compared to infant circumcision. This is because someone who has voluntarily undergone a surgery to combat the spread of disease (versus someone who was surgically altered before the advent of consciousness) may behave quite differently when it comes to adopting safe-sex practices. That is, we cannot draw inferences about the latter sort of person based upon evidence pertaining exclusively to the former sort of person. Second, adult circumcision raises far fewer ethical concerns: not even the most fanatical of “intactivists” would argue that adult men should be prohibited from having their own foreskins removed if that is what they desire.
What about the other STIs you mention? The latest systematic review and meta-analysis on this question reaches a conclusion very different from yours:
The claim that circumcision reduces the risk of sexually transmitted infections has been repeated so frequently that many believe it is true. In studies of general populations, [however], there is no clear or consistent positive impact of circumcision on the risk of individual sexually transmitted infections. Consequently, the prevention of sexually transmitted infections cannot rationally be interpreted as a benefit of circumcision, and any policy of circumcision for the general population to prevent sexually transmitted infections is not supported by the evidence in the medical literature.
Altogether, then, your citation of studies that show only benefits for circumcision (and your facile dismissal of those that point to the possibility of any downsides) is rather selective, to say the least. In fact, it reminds me of that very same “devilishly clever sophistry dressed up as logic” you referred to in your article.
You mention the term “genital mutilation” being used to refer to circumcision, and peg it to a “vitriolic mob of commentators.” I will say that I don’t much like the use of this term myself, as nobody likes to be told that they’ve been “mutilated” (among other reasons). But it’s worth mentioning that even thoughtful, sober legal scholars as well as respected bioethicists have used the term “mutilation” in this context as well — in part, no doubt, because certain forms of genital cutting that are actually less invasive than male circumcision are unambiguously classified as “mutilations” by the World Health Organization. This includes the ‘pricking’ of the clitoral prepuce of young girls (which does not remove any tissue and does not impair function, but which is nevertheless federally banned in the United States). A fortiori, the argument goes, non-therapeutic circumcision of young males must also be a mutilation, since it removes 1/3 or more of the motile skin system of the penis.
Now, you do get some things right. The idea that the foreskin has “mythical powers” is very silly indeed. It has no such powers. But it does consist of sexually sensitive tissue (whose sensitiveness may certainly vary from male to male); it does serve gliding and lubricating functions during sex (which are eliminated by circumcision and which do not seem self-evidently unimportant); and thus it might be at least reasonable to raise a question about the propriety of removing this tissue before the person whose penis it is has had a chance to make his own decision. In medical ethics, irreversible surgeries of any kind are generally treated with great caution, especially when there is no disease or deformity present, and even more so when the patient is incapable of giving consent.
So, no, circumcised men are not all damaged goods nor condemned to having terrible sex lives: that is clearly not the case, as circumcised men will generally attest. (Incidentally, many “circumcised” females report that they enjoy their sex lives as well, despite being told how ‘mutilated’ they are by the WHO.) But some men DO feel harmed by their circumcisions, either because the operation was botched (which should be an impermissible risk for any non-consensual, non-therapeutic surgery), or because they feel violated in having had a healthy, functional, and erogenous part of their penis removed before they had an opportunity to say ’no’.
Of course, if it were any other part of the body we were talking about in this regard, most people would find this to be a fairly reasonable emotional reaction.
Finally, you seem to misunderstand the meaning of the words “medically unnecessary” — a term you attribute to those nutty “intactivists” in reference to non-therapeutic infant circumcision. Just because some health benefits may possibly ensue from removing a part of the body (and it’s unclear that net health benefits even do ensue in the case of circumcision, as discussed above), this does not make the surgery necessary, much less ethically sound. For example, we could eliminate breast cancer by removing the breast buds of all infant girls — and that would be an extraordinary medical benefit. However, infant prophylactic breast bud removal is not only “medically unnecessary” but is quite clearly morally impermissible. Furthermore, UTIs can be treated with oral antibiotics (as they are for girls, who get them 10 times more frequently), and STIs can be prevented by safe sex practices (as they are in Europe, where circumcision is rarely performed, and where STIs are, if anything, actually less of a public health concern). Of course, if an adult male would like to get himself circumcised as a way to reduce his risk of becoming infected with an STI–despite the fact that the evidence in this area is rather murky, and despite the fact that he would have to wear a condom either way–that is certainly up to him. It’s quite a different matter, however, to remove healthy tissue from an infant based upon a rough guess about his future sexual behavior.
In the final analysis, there can be no doubting that certain “fringe” individuals take anti-circumcision arguments to extremes. But it would be a mistake to imply, as your article rather boisterously does, that the only people who are opposed to circumcision are “wacky” activists — or, I’m sorry, “wack-job” intactivists, as the Twitter manager for Slate put it in linking to your article:
Instead, respected medical organizations including the Royal Dutch Medical Association (KNMG) have come out strongly against the practice, for many of the reasons I have already discussed. The KNMG states:
The official viewpoint of KNMG and other related medical/scientific organisations is that non-therapeutic circumcision of male minors is a violation of children’s rights to autonomy and physical integrity. Contrary to popular belief, circumcision can cause complications – bleeding, infection, urethral stricture and panic attacks are particularly common. KNMG is therefore urging a strong policy of deterrence. KNMG is calling upon doctors to actively and insistently inform parents who are considering the procedure of the absence of medical benefits and the danger of complications.
My best guess is that your views on circumcision are rather heavily informed by (and perhaps even constrained by) the default norms of American society, which sees non-therapeutic genital cutting* of boys to be an unremarkable affair. Your mostly-American readers, therefore, may happily lap up your attack on “intactivists” as being right on the money. But the US has a very strange history in adopting circumcision as a cultural norm; circumcision has become uniquely and unthinkingly embedded in American medical practice; and the rest of the developed world views us** with a mix of curiosity and disbelief. Why do Americans continue to circumcise their sons? It is not exactly crazy to take this question seriously.
Brian D. Earp
University of Oxford
* Apologies for my “progaganda-style” (as you put it) use of the term “genital cutting” here, rather than “circumcision”; I was looking for a synonym since I’d already used “circumcision” earlier in the sentence. Since “genital cutting” is a medically accurate as well as value-neutral term, however, I thought this should be OK; and certainly it is a more descriptive choice than the Latin-derived “circumcision” which rather euphemistically draws attention away from what it is that is actually being done.
** Although my current affiliation is the University of Oxford, I am American, and was born and raised in the United States.