Sunday, 28 February 2010

Oh dear: Christiane Northrup on circumcision

Christiane Northrup's article entitled "We Need To Stop Circumcision" has already received some criticism from other bloggers. I thought I'd add my own thoughts...

In the weeks ahead, the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) are likely to publish a recommendation that all infant boys undergo circumcision. In the weeks ahead, the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) are likely to publish a recommendation that all infant boys undergo circumcision. This is a huge mistake. Circumcision is an unnecessary procedure that is painful and can lead to complications, including death. No organization in the world currently recommends this. Why should we routinely remove normal, functioning tissue from the genitals of little boys within days of their birth?

Let's address these arguments one by one:

  1. It's unnecessary, painful, and can lead to complications.
  2. Yes, it's unnecessary, but parents do many things for their children that aren't strictly necessary, from vaccinations to good diet to education. They may not be required, but that doesn't mean that they aren't beneficial. Painful? Yes, if anaesthesia isn't used. Complications? Yes, there's a risk, but that has to be weighed against the risks associated with lack of circumcision.
  3. No organisation currently recommends it. That's not a rational argument for saying that no organisation should recommend it not. Intact America made the same mistake; I analysed their argument here.

  4. Why should it be done? This isn't strictly speaking an argument, so I'll leave it for now.

The vast majority of the world's men, including most Europeans and Scandinavians, are uncircumcised. And before 1900, circumcision was virtually nonexistent in the United States as well--except for Jewish and Muslim people, who've been performing circumcisions for thousands of years for religious reasons. Believe it or not, circumcision was introduced in English-speaking countries in the late 1800s to control or prevent masturbation, similar to the way that female circumcision--the removal of the clitoris and labia--was promoted and continues to be advocated in some Muslim and African countries to control women's sexuality. [1]

The facts: about a third of men — perhaps 40% — are circumcised worldwide. Some physicians advocated circumcision to prevent masturbation in the late 1800s, and anti-circumcision activists are fond of quoting them, but there's no evidence that this was the main reason for the introduction of circumcision, and it certainly wasn't the only one. In fact, Gollaher, in his book "Circumcision: A History of the World's Most Controversial Surgery" (which is one of the more neutral books on the subject) dedicates a mere 12 of his 253 pages to the subject of masturbation.

Routine female circumcision, which has been practiced in some cultures, is completely unacceptable. Few people would argue otherwise. In fact, the United Nations has issued a decree against it. Circumcision is a form of sexual abuse whether it's done to girls or boys. We justify male infant circumcision by pretending that the babies don't feel it because they're too young and it will have no consequences when they are older. This is not true. Women who experience memories of abuse in childhood know how deeply and painfully early experiences leave their marks in the body. Why wouldn't the same thing apply to boys?

As I have explained previously: It is not meaningful to compare female genital cutting to circumcision. Female genital cutting is a net harm, with no known medical benefits, immediate risks, and a considerable chance of permanent harm. Society passes laws to protect the vulnerable from harm, and so it makes sense to protect children from female genital cutting. But - applying the same principle - it doesn't make sense to legislate against circumcision, because there is no net harm. Most reasonable people, weighing the risks and benefits, come to the conclusion that it is neutral or beneficial.

In medical school, I was taught that babies couldn't feel when they were born and therefore wouldn't feel their circumcision. Why was it, then, that when I strapped their little arms and legs down on the board (called a "circumstraint"), they were often perfectly calm; then when I started cutting their foreskin, they screamed loudly, with cries that broke my heart? For years, in some hospitals, surgery on infants has been carried out without anesthesia because of this misconception!

Doubtless this argument is chosen for emotional appeal, but rationally, there's a strong case against circumcision without anaesthesia, but that's not an argument against circumcision.

From the 1980s through today, as the tide has been turning against male circumcision, misleading medical information has begun to surface (yet again) in support of circumcision. This information supports the belief that men with foreskins are more likely to get viral or bacterial infections and pass them on; that the foreskin is tender and thin, and therefore more prone to tiny cuts through which germs can be transmitted. New justifications, such as circumcision to prevent penile and cervical cancer, too often receive the blessing of the medical establishment. But these are justifications that science has been unable to support. Nor is there any scientific proof that circumcision prevents sexually transmitted diseases.

It's difficult to know how to respond to this. How should one respond to someone who plainly states such falsehoods?

This includes the recent studies done in Kenya, South Africa, and Uganda by Ronald H. Gray, a professor at Johns Hopkins University. He recently reported that men who were circumcised were less likely by half to contract HIV virus and less likely by one-third to become infected with HPV and herpes. [2]

As a point of accuracy, Gray did not perform all three studies.

While this sounds promising, I agree with my colleague George Denniston, M.D., who said, "The United States has high rates of HIV and the highest rate of circumcision in the West. The "experiment" of using circumcision to stem HIV infection has been running here for decades. It has failed miserably. Why do countries such as New Zealand, where they abandoned infant circumcision 50 years ago, or European countries, where circumcision is rare, have such low rates of HIV?" [3]

It's concerning to see this argument made by an educated person. Comparisons between selected countries are meaningless. Consider the following image. It's a simulation of HIV rates in 200 hypothetical countries (a very primitive simulation, for purposes of illustration only). The vertical axis represents HIV rates (you can ignore the horizontal axis). The black points represent countries with high circumcision rates — the average HIV rate is 1. The red points represent countries with low circumcision rates — the average HIV rate is 2. So, on average, countries with low circumcision rates have higher HIV rates. But because of the fact that the ranges overlap, it's easy to find black points that are higher than several red points. Let me make that point more clearly: we should expect to be able to find countries with high circumcision rates that have higher HIV rates than some selected countries with low circumcision rates. This is the case with real HIV rates, too (as well as rates of other diseases), and it happens because, in addition to random variation, there are other factors that affect the rates, such as levels of education, condom usage, sex practices, etc.

Country-level comparisons are extremely weak, even when you use a large sample of countries. They're nothing but a joke when small numbers of selected countries are compared. There's really no substitute for rigorous epidemiological studies.

Similarly, one of the main reasons people choose to have their child circumcised is they believe that it's nearly impossible to keep an uncircumcised penis clean. This also isn't true. And people make the mistake of thinking that they have to retract the foreskin to keep it clean. They don't. In fact, retracting the foreskin before it's meant to be retracted creates adhesions and infections. It sometimes doesn't retract on its own until a boy is as old as seven. Often, there isn't an opening between the glans penis and the foreskin. So you gently retract it every year on the child's birthday until it's fully retractable. Only then does it need to be cleaned, and you can teach a boy exactly how to do this.

It seems to me that Northrup is setting up a straw man here. Nobody is arguing that it is "nearly impossible" to keep an uncircumcised penis clean. But it is difficult to deny that it does require a little more work, and also that a circumcised penis is, on average, cleaner.

Emotions run very high around the subject of circumcision, a perfect example of the strength and influence of first chakra cultural programming on our beliefs and emotions. This programming is so ingrained that many people cannot even discuss the subject of circumcision without guilt, denial, or other strong emotions. I know from years of experience that even addressing the subject of the baby boy's bodily integrity, choices, and pain isn't enough to change a belief that's been ingrained in the child's parents from their own birth.

Reading between the lines a little, I think Northrup is saying that she has been unable to persuade parents of her viewpoint. Maybe that's because it isn't very persuasive?

(I'm skipping two paragraphs here.)

Circumcision also has profound implications for male sexuality. Studies document that the amount of pleasure a man can receive during intercourse is greater in uncircumcised males. That's because the male foreskin, like the clitoris, is richly innervated for maximum sexual pleasure. Sexual researchers have determined that men with the original configuration (with the foreskin) are more likely to feel the most pleasure when they make love in a certain way. Without getting into details here, as it turns out, this "natural" sex is more likely to enhance a woman's pleasure, too. I've written about this extensively in Women's Bodies, Women's Wisdom.

Actually, studies have documented no such thing. What they actually indicate, on balance, is that there is basically no difference. It is disturbing that Northrup misrepresents the evidence.

Tuesday, 16 February 2010

CDC consultation report

Male Circumcision in the United States for the Prevention of HIV Infection and Other Adverse Health Outcomes: Report from a CDC Consultation has now been published.

It is a lengthy document, worth reading in full. I'll just highlight here what I think are the most interesting recommendations:

  • With respect to HIV prevention, MC should be framed as one of several partially effective risk-reduction alternatives for heterosexual men that should be used in combination for maximal protection.

  • Recommendations for infant and adolescent/adult MC should be framed as interventions to promote genital health and hygiene, including HIV, STI, and UTI prevention and other outcomes.

  • Recommend reimbursement for MC by public and private insurers to ensure equal access across states, to all socioeconomic groups, and in special settings (e.g., military or prisons).

  • In collaboration with other HHS agencies and health insurers, assess public and private insurance coverage for elective neonatal MC.

  • Medical benefits outweigh risks for infant MC, and there are many practical advantages of doing it in the newborn period.

  • Benefits and risks should be explained to parents to facilitate shared decision-making in the newborn period.
    CDC, AAP, and others should make/update recommendations about infant circumcisions for HIV and broader health concerns.

  • Develop educational resources about infant circumcision for parents, practitioners, and the public.

Wednesday, 10 February 2010

Deliberate distortion from anti-circumcision activist

I spent some time trying to decide whether I should post this. It was a difficult decision for me. On one hand, what follows is part of a message to a private mailing list, and those posting to such lists do so with the expectation of privacy. On the other hand, it illustrates intent to mislead on the part of a prominent anti-circumcision activist, and people have a right to know about this sort of thing.

In the end, I decided to post it.

Hugh Young is a well-known anti-circumcision activist (or "intactivist", as they often call themselves) from New Zealand. He is the owner of the "" website.

INTACT-L is a mailing list run by the anti-circumcision website "", for discussion of anti-circumcision issues in general.

Recently, participants on INTACT-L have been discussing the anticipated policy statement from the American Academy of Pediatrics. One participant suggests that the anti-circumcision activists write a statement for the AAP:

Rather than waiting for them to do the wrong thing, as they surely will, let's tell them what the right thing is.

To which Hugh Young replies:

From: Hugh Young
Subject: Re: The AAP's new position statement on circumcision
Date: Feb 10, 2010 7:23:56 AM


A good point. Brian Morris drafted his version of a statement for the RACP but it was so over the top they would have laughed at it (though they still haven't issued theirs). We need to make ours something they could/should agree to. If it gets published so that people mistake it for the real thing, so much the better. If we can ease them out of legal action for past circumcisions, they'd appreciate that too - that's their big fear if they go straight from "neutrality" to condemnation without giving all present victims time to die off.

(Emphasis added.)

Now, if anti-circumcision activists want to write a "policy statement" for the AAP, that's up to them. It seems a waste of time to me, but it's their time to waste, after all. What I find really alarming here is that Young explicitly indicates that he wants to mislead people. He wants people to believe that the (hypothetical) version authored by the anti-circumcision lobby is the real policy statement.

I'm sorry to say that I believe that what's unusual here is the admission rather than the intent, but even so the admission is startling enough. It makes one think: if the anti-circumcision "message" is so strong, why would anyone feel the need to deceive people?

Does he not have any concept of ethics? Apparently not.