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.

40 comments:

Sam said...

So, I'm uncut, and it's fine. I thought your analysis of these issues was interesting. The only thing that made circumcision a bit rough was when the kid next to you saw that you were "different" when peeing at a urinal. After about age 10 that quit being such a big deal, and now I'm grateful. Also, saying that having an uncircumcised penis is "a little more work" is like saying it's a little more work to wash your hands after using the bathroom. I mean, common courtesy is to double check before the action happens. Just wash up like you would wash your hands! It's just a body part people!! :)

Anonymous said...

You have so many problems with the statements you've made in this blog.

You so quickly dismiss the complications of circumcision. Complications which are irreversible. Where as the so called "risks" of not circumcising are very easily managed.

And on your claim about the percentage of the world's males who are circumcised. One third is not forty percent. I'm not sure how you decided to round up 33% to 40%. I've never seen any statistic stating anything higher than one out of three. Considering that Muslims circumcised and Muslims make up about 21% of the world's population, you can extrapolate that less than 11% of males are circumcised for non-religious reasons.

Female circumcision vs male circumcision. Why is it a horrible abuse to cut off even a smart part of the female genitalia but it's perfectly acceptable to cut off the male foreskin? You can easily make the same arguments arguing for female circumcision as you can for male. How do we know that there is no medical benefits for female circumcision? Couldn't it be cleaner? Think of all those folds that bacteria get caught up in. So many women get infections that could easily be prevented by clipping away some of that excess skin. As far as the argumement that circumcision lowers the risk of transmitting HIV, that's actually a very poor defense. There are many better, more simple and less traumatic ways to prevent HIV. And again, the higher risk of penile cancer for uncircumcised males are related to HPV, a sexually transmitted disease. And the same reasoning I used for preventing HIV applies to HPV.

You claim that the uncircumcised penis is more difficult to clean, but I heartily disagree. My son is not circumcised and his penis requires no more attention then cleaning any other part of his body, much less, actually, then washing his fingers or ears. I'm not sure how you can argue that the circumcised penis is on average cleaner. I suppose that might be true for someone who refuses to clean themselves, but I believe, on average, most penises are equally clean if the individual has healthy hygiene habits. But I suppose if you plan on not teaching your child how to wash himself on a regular basis, then maybe it would be prudent to circumcise.

And as far as sexuality and the foreskin goes, I've actually seen several scientific articles showing research that indicates that the foreskin does have a sexual function. You brush off these claims, but there is evidence. The summary of the research can be found, with footnotes, on this website:
http://www.cirp.org/library/sex_function/

Jake said...

To respond to Anon's comment dated 1 March 2010 06:45:

You so quickly dismiss the complications of circumcision. Complications which are irreversible. Where as the so called "risks" of not circumcising are very easily managed.

That doesn't seem very accurate to me. For example, HIV (of which a certain number of cases are attributable to non-circumcision) is not "very easily" managed, but is in fact difficult and expensive to manage, and ultimately terminal. So I think it would be more accurate to say that many risks associated with lack of circumcision are easily managed, and similarly many risks associated with circumcision are easily managed. As I said, it's necessary to weigh the two against each other.

And on your claim about the percentage of the world's males who are circumcised. One third is not forty percent. I'm not sure how you decided to round up 33% to 40%.

If I were rounding I'd just quote one of the figures. I actually said: "about a third of men — perhaps 40%", indicating a range of values. WHO estimate 30% globally, or 33% assuming a 5% circumcision rate for medical reasons (See page 8 of this WHO document) Judging by recently published statistics from China, etc., I think 5% is a little low, hence my estimate of 40% as a realistic upper bound.

Female circumcision vs male circumcision. Why is it a horrible abuse to cut off even a smart part of the female genitalia but it's perfectly acceptable to cut off the male foreskin? You can easily make the same arguments arguing for female circumcision as you can for male. How do we know that there is no medical benefits for female circumcision?

We don't know. All we can do is to use the best information available to us. But we should always be willing to revisit our analyses following new information.

You claim that the uncircumcised penis is more difficult to clean, but I heartily disagree. My son is not circumcised and his penis requires no more attention then cleaning any other part of his body, much less, actually, then washing his fingers or ears. I'm not sure how you can argue that the circumcised penis is on average cleaner. I suppose that might be true for someone who refuses to clean themselves, but I believe, on average, most penises are equally clean if the individual has healthy hygiene habits.

By imposing such a condition, though, you're no longer talking about the average penis. An average of the population must include those with good, as well as those with less good, hygiene habits. Also, when you take account of the ability to accumulate smegma and bacteria between washes, the circumcised penis will, on average be somewhat cleaner. I'm not saying that it will necessarily be so to a large extent, and it may not actually matter much in the general scheme of things, but I think it is important to recognise it.

And as far as sexuality and the foreskin goes, I've actually seen several scientific articles showing research that indicates that the foreskin does have a sexual function. You brush off these claims, but there is evidence. The summary of the research can be found, with footnotes, on this website:
http://www.cirp.org/library/sex_function/


I'm quite familiar with CIRP, thank you. :) The trouble with that site is that they are very selective, only citing information that supports their case. A more scientific approach is to look at all the evidence and ask whether it supports the case on balance.

Mother of two said...

A foreskin is as much an accident of nature as your eyelids are, I just wanted to bring that to your attention. What other natural body parts are we removing from infants? None- because they are all useful and the removal of baby foreskin is a social disease that has been going on for decades. It is time we stop trying to justify this act and put a stop to it.

HIV can be PREVENTED (not reduced- as in the argument for circumcision) by making your partner take a test and not sleep with an infected person. I plan on warning my children about STD's, and no matter what type of skin you have or what type of penis you have you are still at full risk when sleeping with an infected person. It's not as if someone will continue to sleep with an infected person just because they are circumcised and hoping for the best- they might as well use a condom.
The truth is- there is no real medical reason for it, any permanent surgery should be performed only at the patient's consent, there is NO reason not to give the man a choice because he is unlikely to be sleeping with infected people before he is of age to decide for himself, & because circumcision can be performed at ANY age.

Jake said...

Thanks for your comment, Mother of two.

Just to reply to one part of it, you wrote: "there is NO reason not to give the man a choice because he is unlikely to be sleeping with infected people before he is of age to decide for himself, & because circumcision can be performed at ANY age."

While circumcision can be performed at any age, the risk of complications is smallest when performed in infancy, and the medical benefits greatest. Consequently, many people (including myself) believe that the best time to perform circumcision, if it is to be done, is during the first weeks of life.

Anonymous said...

Different annon than the first.

In your response to mother of two you said:

While circumcision can be performed at any age, the risk of complications is smallest when performed in infancy, and the medical benefits greatest. Consequently, many people (including myself) believe that the best time to perform circumcision, if it is to be done, is during the first weeks of life.

I am curious how benefits are the greatest when circumcised as an infant, when you stated in this blog that cleanliness and STD's are a major concern and reason to circumcise. We all know that an infants, toddlers, and for some boys up til puberty foreskin is attached and there for bacteria cannot get up and grow under the foreskin. And for infants and young boys there should be no sexual activity unless there is abuse. So how are infants and young children so greatly benefited from circumcision in the first few weeks of life? The reasoning is that they heal quickly, the same reasoning can be applied that there not need to be any healing at all. There are no immediate benefits to a healthy infant, and the main reason you are including in this post are irrelevant until puberty or later.

Jake said...

To the (other) Anon, who wrote in a comment dated 1 March 2010 23:00:

I am curious how benefits are the greatest when circumcised as an infant, when you stated in this blog that cleanliness and STD's are a major concern and reason to circumcise.

In the interests of accuracy, I haven't actually said that. I do think that STDs are a serious concern, but cleanliness is not a major issue by itself.

We all know that an infants, toddlers, and for some boys up til puberty foreskin is attached and there for bacteria cannot get up and grow under the foreskin.

No, that's not really the case. Because of the gradual separation of the foreskin, pockets develop that are entirely suitable for the growth of bacteria.

And for infants and young boys there should be no sexual activity unless there is abuse. So how are infants and young children so greatly benefited from circumcision in the first few weeks of life?

Okay, here are a few of the obvious benefits:

Firstly, UTIs. In males, these are most frequent (and potentially most dangerous) during the first year or so of life, and they are about 7 times more likely to affect uncircumcised boys. The frequency is lower through childhood, but even so by age 16 or so the difference between circumcised and uncircumcised boys is 3 or 4 percentage points.

Secondly, balanitis and other forms of local inflammation affect uncircumcised males disproportionately. As with UTIs, this continues throughout life, but the benefit that is accumulated through childhood is perhaps 3-4%.

Thirdly, penile cancer. Studies have consistently found that neonatal circumcision protects against penile cancer, particularly invasive forms, but the evidence re later circumcision is much less consistent: it might be protective, but it is difficult to be sure. This is a relatively rare condition (affecting perhaps about 1 in 900 uncircumcised males over a lifetime), but it is serious.

James said...

Jake,

Regarding the benefits of an infant circumcision, you're parroting hollow statistics from the extremist end of the pro-cutting crowd. I say hollow, as no-one has ever been able to demonstrate real-world of benefit of circumcision. That is, what's the U.S. got to show for generations of near-universal circumcision compared to non-cutting first-world countries? Lower rates of penile cancer, cervical cancer, UTIs, AIDS, infant mortality - anything...?

And are non-cutting countries suffering from the dreaded diseases circumcision is meant to prevent? Nope.

Even if all the potential medical benefits were proven, this would still be no valid justification for performing a permanent surgical procedure on an individual who cannot possibly consent. This is an issue of basic human rights and medical ethics.

Parents decisions do not extend to modifying their child's foreskin by piercing, tattooing, branding, beading or scarification, any yet some people still believe they have a right to authorize the far more damaging complete amputation of the inner and outer foreskin and frenulum tissue for what amounts to cultural and cosmetic reasons.

You say up to 40% of the world's males may be circumcised. This seems very high. Yes, I know WHO states 30%, but around 15% seems to be more widely quoted and accepted. Remember, it's really only Muslims, Jews and Americans that circumcise their males. I have read that only 1% of infant males are circumcised, and 90% of these occur in America.

Babies suffer extreme pain. Adverse outcomes are common and men have to live with the consequences. Sometimes babies die.

Is it too much to ask that doctors simply observe the legal norms and medical ethics which apply to every other body part of male and female children?

A parent's desire to amputate healthy functional tissue from a defenseless child (no matter how well intentioned), should never, ever outweigh the fundamental human right of a healthy child to not to have his genitals interfered with and mutilated?

It's often said that the more you know about circumcision, the worse it gets. Keep researching, Jake! I'll be looking forward to your next blog on the rights of all children to the security of their own body and protected from unnecessary genital cutting.

Jake said...

Hello James,

This is part 1 of my reply.

Regarding the benefits of an infant circumcision, you're parroting hollow statistics from the extremist end of the pro-cutting crowd. I say hollow, as no-one has ever been able to demonstrate real-world of benefit of circumcision. That is, what's the U.S. got to show for generations of near-universal circumcision compared to non-cutting first-world countries? Lower rates of penile cancer, cervical cancer, UTIs, AIDS, infant mortality - anything...? ... And are non-cutting countries suffering from the dreaded diseases circumcision is meant to prevent? Nope.

As I pointed out in my original post, comparisons between individual countries are inherently unreliable. In addition to the potential problem of comparing outliers, which I illustrated, they are also particularly susceptible to confounding. To determine the effect of circumcision you have to compare circumcision with lack of circumcision. A country-level comparison cannot isolate the effect of circumcision, though - it can only compare the effect of the sum of all differences between countries.

In epidemiology, ecological analyses (which is what between-country comparisons are called) are regarded as one of the weakest of all study designs. They're generally considered to be good only for generating hypotheses. To assert that higher quality studies are flawed because their results differ from ecological comparisons is backwards, to say the least.

Even if all the potential medical benefits were proven, this would still be no valid justification for performing a permanent surgical procedure on an individual who cannot possibly consent. This is an issue of basic human rights and medical ethics.

Apparently you see an issue that others, including myself, do not. I see no ethical or human rights issues involved with a procedure that is a net benefit.

Jake said...

And here is part 2:

You say up to 40% of the world's males may be circumcised. This seems very high. Yes, I know WHO states 30%, but around 15% seems to be more widely quoted and accepted.

Surely the issue is which is most likely to be correct, not which is most widely quoted?

Remember, it's really only Muslims, Jews and Americans that circumcise their males.

No, that's not the case. There are several other populations (eg., South Korea, as well as several parts of Africa) with high non-religious circumcision rates. The WHO estimate is the sum of all these (religious and non-religious); see page 8 of their report.

Babies suffer extreme pain. Adverse outcomes are common and men have to live with the consequences. Sometimes babies die.

I think you're overstating your case. The procedure is associated with extreme pain if anaesthesia isn't used, but the solution to that is simple and obvious. Complications are rare, and serious complications even more so.

Is it too much to ask that doctors simply observe the legal norms and medical ethics which apply to every other body part of male and female children?

In my view doctors already do so. To my knowledge, no surgical procedure on any other body part carries the same benefit:risk balance. Let me put that another way: can you think of any procedure which is a net benefit (or even neutral) to perform? If there is such a procedure, then there is no obvious ethical problem with performing it, since ethical and legal prohibitions against causing harm do not apply.

A parent's desire to amputate healthy functional tissue from a defenseless child (no matter how well intentioned), should never, ever outweigh the fundamental human right of a healthy child to not to have his genitals interfered with and mutilated?

The problem is that this "human right" is merely an invention of anti-circumcision activists.

It's often said that the more you know about circumcision, the worse it gets. Keep researching, Jake! I'll be looking forward to your next blog on the rights of all children to the security of their own body and protected from unnecessary genital cutting.

I'm afraid I wouldn't hold your breath, James. I started researching this subject in earnest in about 2003, and at first I was mildly opposed to infant circumcision. Over time, my views shifted to a pro-parental choice position. I firmly believe that one should always be willing to change one's position in response to new data, though, so it is always possible that my views might once more change. But somehow I find that unlikely.

James said...

Jake,

I'm afraid I cannot agree with any of your points.

As in my last, it's not a medical issue. It's a human rights issue. Doctors cutting healthy, erogenous functional tissue from children's bodies is a gross violation of human rights and medical ethics. There would need to be absolutely extraordinary evidence to justify the removal of healthy body parts, not some vague 'potential' benefit or even a net benefit.

Let's explore net benefit.

Of course comparisons between countries are difficult. (Perhaps someone should let the CDC and AAP know that cut-short trials on consenting African men may not translate to American babies.) But it seems that not only has the U.S. got NOTHING to show for removing the foreskins from up to 100 million boys, the U.S. has among the WORST sexual health in the developed world. Are neighboring intact Canadian babies getting more UTIs than American babies? Claims of benefit are complete bullshit. Doctors make good money from cutting babies and that's the root of the health myth. If the U.S did have better health 'numbers', have no doubt this would be used as evidence. As it is, it's an inconvienient thruth that needs to be explained away.

Recent statements on circumcision from the respective medical bodies in Canada and Australia / New Zealand - all cutting cultures once upon a time - do not claim a net benefit. They do give consideration to the legality of the procedure, medical ethics and human rights. The U.K. was once a cutting culture also but now abandoned the the practice. The health of boys and men has not been adversely impacted in any way with the demise of circumcision.

In August 1999 the Royal Australiasian College of Physicians (Paediatrics & Child Health Division) said:
After extensive review of the literature the RACP does not recommend that routine circumcision in infancy be performed.

In September 2009 The College of Physicians and Surgeons of British Columbia said:
Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western countries. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non‐therapeutic and medically unnecessary intervention.

Current British Medical Association guidance:
Doctors should ensure that any parents seeking circumcision for their son in the belief that it confers health benefits are fully informed of the lack of consensus amongst the profession over such benefits, and how great any potential benefits and harms are. The BMA considers that the evidence concerning health benefit from non-therapeutic circumcision is insufficient for this alone to be a justification for doing it.

cont...

James said...

Cont...

An interesting observation from circinfo.org:
The reasonable conclusion, that the rising incidence of circumcision over the first half of the twentieth century made no contribution to improved child health outcomes, is confirmed by a recent report from the Australian Institute of Health and Welfare covering the period 1983 to 2003. The report, A picture of Australia’s children 2005, shows major improvements in child health over the 20 years from 1983 to 2003, and a halving of infant mortality. These are very significant dates, since 1983 was the beginning of the dramatic slide in Australian circumcision incidence, from about 40 per cent of boys in the early 1980s to less than 12 per cent in 2003. It is thus good empirical proof that “lack of circumcision” does not increase child health problems. Even more significantly, it is a decisive refutation of “scientific” predictions by various antiquated circumcision enthusiasts that the fall in the circumcision rate would lead to an explosion of genito-urinary problems in boys. No such problems are identified in this report, which does not even mention any health problems affecting the genito-urinary area. If one were to be as unscrupulous in mixing up correlation with causation as many pro-circumcision zealots tend to be, one could reasonably conclude that Australian children have become healthier because the incidence of circumcision has fallen, not merely at the same time. But there is no need to go that far. At the very least A picture of Australia’s children is definitive proof that there is zero connection between circumcision and improved health outcomes.


So yes, comparisons between countries are difficult, but there is clear evidence that the health outcomes of boys has certainly not suffered in any way (and indeed has only improved) within countries where circumcision was once common and have now abandoned the practice.
t.


30-40%. I read the WHO report. It still seems high when you consider the regions of the world where circumcision is not generally practiced. India, China (indeed the vast majority of Asia), Europe, Scandanavia, South America, Oceania. There doesn't seem to be 40% left after that! I suspect people tend over-state circumcision rates to make circumcision somehow seem normal. One thing is clear from the numbers, and that only the U.S. is cutting children on the basis of a potential health benefit myth.


I must say, it's very heartless and uncaring of you dismiss the very real harm and suffering caused by unnecessary genital cutting. Adverse outcomes are not uncommon and death is not unheard of.

It's also completely unacceptable that parents are making decisions on a cosmetic surgical procedure on children which has a life-long impact. The child should have a say. 5 of 6 Australian states have banned circumcisions from their public hospitals as it's a 'cosmetic' procedure. Exceptions are made for cases of genunine medical need, which is consistent with medical practice for every other part of a child.

As a matter of principle, people need to decide whether it's acceptable to restrain a minor and cut away healthy flesh or whether it's not acceptable. I'm yet to see a valid argument for why the protective covering of a male child's penis should be treated any differently to any other body part.

Jake said...

Hello James,

As in my last, it's not a medical issue. It's a human rights issue. Doctors cutting healthy, erogenous functional tissue from children's bodies is a gross violation of human rights and medical ethics. There would need to be absolutely extraordinary evidence to justify the removal of healthy body parts, not some vague 'potential' benefit or even a net benefit.

I guess it's reasonable that we can disagree on this. To my mind, net benefit is more than sufficient.

Of course comparisons between countries are difficult. (Perhaps someone should let the CDC and AAP know that cut-short trials on consenting African men may not translate to American babies.)

(Extrapolation of data from one country to another is not the same as comparison between the two.)

But it seems that not only has the U.S. got NOTHING to show for removing the foreskins from up to 100 million boys, the U.S. has among the WORST sexual health in the developed world. Are neighboring intact Canadian babies getting more UTIs than American babies?

Forgive me if I'm mistaken, but aren't you just making the same between-country comparisons again?

Recent statements on circumcision from the respective medical bodies in Canada and Australia / New Zealand - all cutting cultures once upon a time - do not claim a net benefit.

Few of them directly address the question of net benefit vs harm. And to be fair, most policy statements on circumcision are rather dated, in particular they were published before the results of the HIV RCTs became available. The main exception is the American Urological Association, which in 2007 recommended that circumcision should be presented as an option for health benefits.

They do give consideration to the legality of the procedure, medical ethics and human rights. The U.K. was once a cutting culture also but now abandoned the the practice. The health of boys and men has not been adversely impacted in any way with the demise of circumcision.

You haven't provided any proof that there has been no adverse effect, and I'm not sure how one would go about doing so.

Jake said...

Part 2:

An interesting observation from circinfo.org:
The reasonable conclusion, that the rising incidence of circumcision over the first half of the twentieth century made no contribution to improved child health outcomes, is confirmed by a recent report from the Australian Institute of Health and Welfare covering the period 1983 to 2003. The report, A picture of Australia’s children 2005, shows major improvements in child health over the 20 years from 1983 to 2003, and a halving of infant mortality. These are very significant dates, since 1983 was the beginning of the dramatic slide in Australian circumcision incidence, from about 40 per cent of boys in the early 1980s to less than 12 per cent in 2003. It is thus good empirical proof that “lack of circumcision” does not increase child health problems. Even more significantly, it is a decisive refutation of “scientific” predictions by various antiquated circumcision enthusiasts that the fall in the circumcision rate would lead to an explosion of genito-urinary problems in boys. No such problems are identified in this report, which does not even mention any health problems affecting the genito-urinary area. If one were to be as unscrupulous in mixing up correlation with causation as many pro-circumcision zealots tend to be, one could reasonably conclude that Australian children have become healthier because the incidence of circumcision has fallen, not merely at the same time. But there is no need to go that far. At the very least A picture of Australia’s children is definitive proof that there is zero connection between circumcision and improved health outcomes.


What they're saying, in effect, is that some unknown quantity caused Australian children to become healthier during this period, and therefore circumcision has no benefit. But, of course, that's illogical: to test the effect of circumcision you need to vary circumcision rates while holding every other variable stable. Varying circumcision rates and simulaneously varying the unknown quantity can give only inconclusive results.

So this is an example of very unclear thinking on the part of circinfo.org.

30-40%. I read the WHO report. It still seems high when you consider the regions of the world where circumcision is not generally practiced. India, China (indeed the vast majority of Asia), Europe, Scandanavia, South America, Oceania. There doesn't seem to be 40% left after that!

Well, try getting some population figures and see what the sums are. Incidentally, don't forget that a certain fraction of the population in these countries will be circumcised. For example, about 12% of Chinese men and 59% of Australian men are circumcised.

I must say, it's very heartless and uncaring of you dismiss the very real harm and suffering caused by unnecessary genital cutting. Adverse outcomes are not uncommon and death is not unheard of.

It's not a case of heartlessness; it's a case of realism. The complication rate is estimated at 0.2%-0.6%; most complications are minor. Death is extremely rare, estimated at about 1 in 500,000. It does happen, and when it does it is tragic, but we need to keep a sense of proportion, and remember that risks associated with non-circumcision can be equally tragic.

James said...

0.2 - 0.6%? Do the math. Your dramatically understating the damage and suffering of children.

"Neonatal circumcision is totally unnecessary, and there is no current role for preventative or prophylactic neonatal circumcision.
Unfortunately, 70-80% of neonatal circumcisions are performed by obstetricians, who can neither manage their complications (2-5% incidence) nor obtain proper informed consent (defined as outlining risks and benefits of a procedure, as well as alternatives-including nothing) for neonatal circumcision. Currently, the American College of OB-GYN (ACOG) have no parameters for training (learning and performing neonatal circumcision, managing complications)of residents, who then go out and continue this
practice.

In my practice, as a pediatric urologist, I manage the complications of neonatal circumcision. For example, in a two year period, I was referred
>275 newborns and toddlers with complications of neonatal circumcision. None of these were 'revisions' because of appearance, which I do not do. 45% required corrective surgery (minor as well as major, especially for amputative injury), whereupon some could be treated locally without surgery.

Complications of this unnecessary procedure are often not reported, but of 300 pediatric urologists in this country who have practices similar to mine...well, one can do the math, to understand the scope of this problem...let alone, to understand the adverse cost-benefit aspect of
complications (>$750,000) in this unfortunate group of infants and young children. Fortunately, neonatal circumcision is on the decline as parents become educated...but the complications still continue.

Until the time that the USA falls in step with the rest of the planet who does not submit newborns to neonatal circumcision, ACOG should assure that the training of obstetricians to perform this procedure is adequate, particularly in avoiding and managing complications of a procedure that is unnecessary, and that obstetricians learn to obtain proper informed consent from parents who have no idea of the problems that can ensue."

M.David Gibbons, MD
Associate Professor, Pediatric Urology, Georgetown University School of Medicine and George Washington School of Medicine.
Attending Pediatric Urologist, Childrens National Medical Center, Washington, DC.
Director, Pediatric Urology, Georgetown University Hospital, Washington, DC.
Head, Pediatric Urology, Inova Fairfax Hospital For Children, Falls Church, Virginia.

James said...

30-40%

Urology Web piece would also suggest the 30-40% figure is overstated.

"Although 80% of the world's population does not practice circumcision, the operation is done either for "health reasons" or as a religious ritual by Moslem, Jews, most black Africans and others. According to some, one reason that circumcision is prevalent in the United States is that medical and popular literature abounds in errors of judgment and obfuscation."

http://www.urologyweb.com/posthitis-balanitis-and-circumcision.html

Jake said...

0.2 - 0.6%? Do the math. Your dramatically understating the damage and suffering of children.

No, I don't think so. And I don't know what you expect to achieve by re-posting a claim of a 2-5% incidence. A claim without evidence is just an empty sequence of words. The source I cited (the AAP's 1999 policy statement) cites large-scale studies as the source for their figures.

Similarly...

Urology Web piece would also suggest the 30-40% figure is overstated.

"Although 80% of the world's population does not practice circumcision, ..."


Again, this provides no indication whatsoever that the 30-40% figure is overstated. It just states a lower figure, with no indication as to how that figure was calculated, and hence no way to assess its reliability. At least provide a source with a clear, repeatable description of how the numbers were calculated, like the World Health Organisation's document.

Come on, James, if you want to debate then — please — let's debate. But to debate we need stronger evidence than "this random person quoted this figure".

James said...

30-40%

661.5 million circumcised males over 15yo from a global male population of 3,321.6 million equals less than 20%. Are you suggesting there's an equal number of circumcised males between 0 and 14yo? Even the uber-creepy Gilgal Society quotes "a quarter" of all males. The WHO / UNAIDS paper also assumes circumcision among Muslims and Jews is 100%, when we know that's not the case, but I guess you only have to look at the authors to get an insight into the bias...

661,500,000 - Proportion of males aged 15 years or older circumcised globally. Global total.
Your source: WHO / UNAIDS, Male circumcision, Global trends and determinants of prevalence, safety and acceptability (2007)

3,321,583,000 - World's male population in 2006
My source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat (2007).

0.2-0.6%

Dr Gibbons notes that complications often go unreported. The mere fact that babies are being harmed during medically unnecessary surgery should be sufficient to bring an immediate end to this brutal, damaging and medically useless practice. Your argument goes like a holocaust denier: do the actual numbers really matter? Parents have no business requesting medically unnecessary surgery for young children and doctors have no business performing it - and profiting from it. Circumcision is a permanent surgical alteration to the boys penis. It is obscene that adults in positions of power inflict this on defenseless infants.

If someone wants to have the best parts of their penis removed as an adult, all power to them. I support the right of consenting adults to do with their own body as they wish, without limitation.

Jake said...

661.5 million circumcised males over 15yo from a global male population of 3,321.6 million equals less than 20%.

I rather doubt that the global population for males aged 15 or more is 3,321.6 million. If it were there would be very few males under 15. Are you sure you're not using the total male population as a denominator by mistake?

Are you suggesting there's an equal number of circumcised males between 0 and 14yo?

I think it would be much more difficult to estimate the proportion in a younger age group, owing to the different ages at which different Muslim societies perform circumcision.

Even the uber-creepy Gilgal Society quotes "a quarter" of all males.

Sorry, I don't follow your argument. Are you saying that the trustworthiness of an estimate is proportional to the "creepiness" of it's source? (I'm making no comment about whether it is or isn't creepy; I'm just trying to find out what your argument actually is.)

The WHO / UNAIDS paper also assumes circumcision among Muslims and Jews is 100%, when we know that's not the case, but I guess you only have to look at the authors to get an insight into the bias...

It will probably overestimate the number of religious circumcisions, but that will be balanced by the fact that it doesn't take account of many cultural or tribal circumcision traditions. As an approximation, it seems reasonable.

...

Dr Gibbons notes that complications often go unreported. The mere fact that babies are being harmed during medically unnecessary surgery should be sufficient to bring an immediate end to this brutal, damaging and medically useless practice. Your argument goes like a holocaust denier: do the actual numbers really matter?

Of course the numbers matter! We need data in order to compare circumcision with non-circumcision. Yes, there's a non-zero risk associated with circumcision, but there is also a non-zero risk associated with non-circumcision. We need the numbers in order to weigh the two against each other.

What you seem to be doing is looking at only half of the picture. You're pointing to the risks associated with circumcision, which are real (though I think you're overstating them somewhat), but you're ignoring the risks associated with lack of circumcision. These risks are no less real, and by ignoring them you're inhibiting your own ability to make a rational assessment.

James said...

I never said the over 15yo population was 3,321.6 million, I said the global male population was 3,321.6 million [in 2007].

Again, my point was that if 661.5 million 15+ year old males are circumcised out of a total male population of 3,321.6 million males (<20%), I want to know where the remainder of the "30-40%" are. There is only the 0-14yo population left. Are you saying it's possible that up to half of the world's circumcised males are children up to 14?

For the avoidance of doubt, I'm saying you are exaggerating the prevalence of circumcision to make it appear more 'normal' and therefore, acceptable.

You also mention it's important to weigh the risks of not circumcising. Two questions:

1. The list of boys damaged and killed by unnecessary circumcisions is long, but I've never heard of a child dying from not being circumcised. Have you?

2. Are the risks associated with not circumcising apparent in non-circumcising cultures (Europe, U.K., New Zealand, Australia, Scandinavia, Japan etc. etc.).

For the avoidance of doubt, I'm saying you are exaggerating the risks of having a whole, normal body and trying to create a fear of not circumcising in a continuation of the tactics used to prop-up the business of medical circumcision for decades.

Jake said...

I never said the over 15yo population was 3,321.6 million, I said the global male population was 3,321.6 million [in 2007].

Again, my point was that if 661.5 million 15+ year old males are circumcised out of a total male population of 3,321.6 million males (<20%), I want to know where the remainder of the "30-40%" are. There is only the 0-14yo population left. Are you saying it's possible that up to half of the world's circumcised males are children up to 14?


No, James, that's not what I'm saying. The World Health Organisation have not made a statement about children of 14 or less. Read what they say carefully. They have stated that "approximately
30% of the world’s males aged 15 years or
older are circumcised". Note that they're not saying that 30% of all males are circumcised; they're discussing a fraction of a smaller population, males who are 15 or older.

So it is incorrect to use the number of males of any age as a denominator. What you should be using is the number of males aged 15 or older as a denominator. Based on the WHO's figures (661.5 x 1/.30) I'd expect this figure to be about 2,200 million.

To illustrate with a hypothetical example, suppose they had said that 50% of the world's black men were Muslim. Put another way, that means that the number of black Muslim men divided by the number of black men is 0.5. It doesn't mean that the number of black Muslim men divided by the number of men is 0.5.

For the avoidance of doubt, I'm saying you are exaggerating the prevalence of circumcision to make it appear more 'normal' and therefore, acceptable.

So I'm doing this by ... hypnotising the World Health Organisation in order to get them to produce favourable figures? :-)

You also mention it's important to weigh the risks of not circumcising. Two questions:

1. The list of boys damaged and killed by unnecessary circumcisions is long, but I've never heard of a child dying from not being circumcised. Have you?


Yes. Urinary tract infections are sometimes fatal, so it's fairly trivial to work out the population attributable risk. Using figures from a 1989 paper, there were 2 deaths in 35,929 uncircumcised patients, both due to complications of UTI, and 0 deaths in 100,157 circumcised boys. (Ref: Wiswell TE, Geschke. Risks from circumcision during the first month of life compared with those for uncircumcised boys. Pediatrics 1989: 83; 1011-5)

2. Are the risks associated with not circumcising apparent in non-circumcising cultures (Europe, U.K., New Zealand, Australia, Scandinavia, Japan etc. etc.).

Yes, studies have been performed in most, if not all of these locations, and have been consistent with those performed in the US.

For the avoidance of doubt, I'm saying you are exaggerating the risks of having a whole, normal body and trying to create a fear of not circumcising in a continuation of the tactics used to prop-up the business of medical circumcision for decades.

I see. A strong accusation indeed.

James said...

Let's get back to basics...

If up to 40% of the global male population of 3,321.6 million males [2007] was circumcised, we would expect to find up to 1,328.6 million circumcised males around the world. You have provided a link showing the locations of 661.5 million [2007] >15yo circumcised males.

By your reckoning, there is potentially up to a further 667 million circumcised males, either under 15yo and/or in places not accounted for by UN AIDS. I noticed Fantasyland wasn't listed in the UN AIDS paper; perhaps they're hiding out there...?

Urinary Tract Infections:

You have not provided details of anyone who has died or been harmed from not being circumcised. You also failed to mention girls get more UTIs than either cut or uncut boys and the standard of care is antibiotics.

Interesting you find Wiswell's decades-old, Army hospital, desktop study compelling. I don't, and apparently not many do. His work has been very widely reported and pre-dates position statements issues by a number of professional medical organisations, including the College of Physicians and Surgeons of British Columbia, the American Academy of Pediatrics, the Royal Australasian College of Physicians and the British Association of Paediatric Surgeons. None of these organisations considered Wiswell's data (or anyone else’s data in favour of circumcision) sufficient to recommend the circumcision of healthy babies. Interesting also that a study by the Department of Pediatrics C, Schneider Children’s Medical Center of Israel found that: "There was a higher preponderance of UTI among male neonates. Its incidence peaked during the early post-circumcision period, as opposed to the age-related rise in females. UTI seems to occur more frequently after traditional circumcision than after physician-performed circumcision." What? Circumcision is CAUSING some UTIs? But you know this, right? For academic interest, how many healthy boys would need to have their (protective, erogenous, innervated, mobile) foreskin surgically removed to potentially prevent a single UTI? An infection easily treated with antibiotics.

Following a meta-analysis of 1,200 circumcision studies, the Annals of Family Medicine reported in January 2010 that: "Current evidence fails to recommend widespread neonatal circumcision for these [sexually transmitted infections, urinary tract infections, and penile cancer] purposes."
Ref: http://www.annfammed.org/cgi/reprint/8/1/64.pdf

And so it would appear that after a hundred and forty years of medical circumcision, this harmful, unethical and creepy practice continues to be a cure in search of a disease. I'm sure doctors who have made millions of dollars circumcising healthy babies appreciate your efforts regardless.

Jake said...

Let's get back to basics...

If up to 40% of the global male population of 3,321.6 million males [2007] was circumcised, we would expect to find up to 1,328.6 million circumcised males around the world. You have provided a link showing the locations of 661.5 million [2007] >15yo circumcised males.

By your reckoning, there is potentially up to a further 667 million circumcised males, either under 15yo and/or in places not accounted for by UN AIDS. I noticed Fantasyland wasn't listed in the UN AIDS paper; perhaps they're hiding out there...?


James, I think you need to clearly state which estimate you wish to discuss. If you wish to discuss the WHO's estimate, you're using incorrect figures. Their estimate is 30%, not 40%. If you wish to discuss my estimate (40%), you're again using the wrong figures, since the WHO's 661.5 figure is plainly a restatement of their 30% estimate. Furthermore, you need to explicitly state the population of interest: do you wish to discuss all males, or those over 15?

You have not provided details of anyone who has died or been harmed from not being circumcised. You also failed to mention girls get more UTIs than either cut or uncut boys and the standard of care is antibiotics.

I've provided data. Do with that what you will. We're discussing boys, so diseases affecting girls are irrelevant.

Interesting you find Wiswell's decades-old, Army hospital, desktop study compelling. I don't, and apparently not many do. His work has been very widely reported and pre-dates position statements issues by a number of professional medical organisations, including the College of Physicians and Surgeons of British Columbia, the American Academy of Pediatrics, the Royal Australasian College of Physicians and the British Association of Paediatric Surgeons. None of these organisations considered Wiswell's data (or anyone else’s data in favour of circumcision) sufficient to recommend the circumcision of healthy babies.

There's something very odd about this conversation. You asked for information about deaths due to lack of circumcision. I provided it. Now you want to discuss whether that data is sufficient to recommend circumcision of healthy babies? To my mind it seems you're changing the subject...

(continued)

Jake said...

(continued)

Interesting also that a study by the Department of Pediatrics C, Schneider Children’s Medical Center of Israel found that: "There was a higher preponderance of UTI among male neonates. Its incidence peaked during the early post-circumcision period, as opposed to the age-related rise in females. UTI seems to occur more frequently after traditional circumcision than after physician-performed circumcision." What? Circumcision is CAUSING some UTIs? But you know this, right?

Absolutely. There are about 3-4 published studies with similar findings. In summary, what happens is that although the risk of UTIs is lower among circumcised boys than uncircumcised boys, the incidence among circumcised boys peaks shortly after circumcision.

For academic interest, how many healthy boys would need to have their (protective, erogenous, innervated, mobile) foreskin surgically removed to potentially prevent a single UTI? An infection easily treated with antibiotics.

Depends on whose figures you use, it could be anything from 1 in 6 to 1 in 200. Best available data suggests that an NNT of 11 is about right.

Following a meta-analysis of 1,200 circumcision studies, the Annals of Family Medicine reported in January 2010 that: "Current evidence fails to recommend widespread neonatal circumcision for these [sexually transmitted infections, urinary tract infections, and penile cancer] purposes."
Ref: http://www.annfammed.org/cgi/reprint/8/1/64.pdf


Ah, yes, the Perera paper. It's actually a meta-analysis of 8 studies, not 1200, and that's the main problem. You see, Perera included only one type of study (randomised controlled trials) in their analysis, rejecting all other types of data. Consequently, it shouldn't be surprising that their results seems a little out of touch.

James said...

The ball's still in your court, Jake. If you reckon there are up to 1,328.6 million circumcised males (40%) around the world, just tell us where they are.

You have still not provided details of anyone who has died or been harmed from not being circumcised. And of course you can't. People no sooner die due to the presence of a foreskin than would die due to the presence of eyelids. You are simply quoting decades-old statistics that no reputable body finds credible or worth risking surgery for.

RACP: August 2009: "The most important conditions where some benefit may result from circumcision are urinary tract infections, and in adults HIV infection and cancer of the penis. The frequency of these conditions, the level of protection offered by circumcision and complication rate of circumcision do not warrant a recommendation of universal circumcision for newborn and infant males in an Australian and New Zealand context." "After extensive review of the literature the RACP does not recommend that routine circumcision in infancy be performed"

In response to my question about how many healthy boys would need to have their foreskin surgically removed to potentially prevent one UTI, you say it could be anything from 1 in 6 (17% of boys) to 1 in 200 (0.5% of boys), whereas I assume you mean you would need to remove somewhere between 6 and 200 healthy foreskins to prevent one UTI. And let's not forget circumcised boys get UTIs too.

Given a reduced risk of acquiring a UTI is the only potential benefit claimed (and only since 1982) for circumcision in childhood, and since UTIs are easily treated with antibiotics, wouldn't it make sense to let an adult choose whether to have a permanent surgical modification (i.e. surgical reduction) to his penis with fully informed consent? This seems a much more ethical approach, compared to performing surgery on a bunch of healthy boys who were never going to have a problem in the first place.

Feel free to chime in at this point with; 'it's a surgical vaccine' or 'a 1 in 3 chance of problems' or 'women prefer it' or 'it prevents gays docking' or 'prevents bathroom splashing' or 'confers a lifetime of benefits' or 'the foreskin can get caught in a zipper' or.....

"Unnecessary genital surgery on babies is said to be cheaper and easier than on adults. All abuse of babies is easier. They are powerless and history will judge us by how we protect the powerless. Do we say to children that they have no say in this because statistically when they grow up and practice unsafe sex they might be better off? I say let the children decide for themselves - all in good time." Paul Mason, Children's Commissioner for Tasmania.

Jake said...

The ball's still in your court, Jake. If you reckon there are up to 1,328.6 million circumcised males (40%) around the world, just tell us where they are.

I've already explained the origin of my estimate. I've taken the WHO's estimate (30%), and have adjusted it upwards to reflect the relatively high rates of non-religious circumcision in populous countries such as China.

You have still not provided details of anyone who has died or been harmed from not being circumcised. And of course you can't. People no sooner die due to the presence of a foreskin than would die due to the presence of eyelids. You are simply quoting decades-old statistics that no reputable body finds credible or worth risking surgery for.

You're mixing up two separate issues. The first is whether circumcision protects against urinary tract infections (a small proportion of which can be fatal). The second is whether that protection is of sufficient magnitude to warrant recommending circumcision as a universal procedure. The first issue is what we were discussing.

In response to my question about how many healthy boys would need to have their foreskin surgically removed to potentially prevent one UTI, you say it could be anything from 1 in 6 (17% of boys) to 1 in 200 (0.5% of boys), whereas I assume you mean you would need to remove somewhere between 6 and 200 healthy foreskins to prevent one UTI. And let's not forget circumcised boys get UTIs too.

Yes, they do, though of course the risk is lower.

Given a reduced risk of acquiring a UTI is the only potential benefit claimed (and only since 1982) for circumcision in childhood,

This is news to me. What about prevention of balanitis? Phimosis? BXO?

and since UTIs are easily treated with antibiotics, wouldn't it make sense to let an adult choose whether to have a permanent surgical modification (i.e. surgical reduction) to his penis with fully informed consent? This seems a much more ethical approach, compared to performing surgery on a bunch of healthy boys who were never going to have a problem in the first place.

To respond to that, I'll copy one of my posts from another blog:

Well, if you want to consider circumcision at birth vs at age 18, there are many factors to consider. These include the following:

(For infant circumcision)

* Partial prevention of urinary tract infections during infancy and childhood
* Partial prevention of balanitis & posthitis during infancy and childhood
* Partial prevention of acquired phimosis during childhood
* Partial prevention of penile cancer in adulthood (studies suggest that only neonatal circumcision confers this benefit)
* Partial prevention of HIV and other STDs in the window between the onset of sexual activity and the hypothetical circumcision at age 18

(For adult circumcision)

* Greater risk of complications
* Greater cost
* Loss of working days
* Loss of sexual activity during healing period
* Embarrassment & anxiety before & after
* Poorer cosmetic outcome due to scarring

I submit that, when you consider it carefully, neonatal circumcision simply makes more sense than circumcision at age 18. Not only does waiting incur a substantial loss of benefit, but it also carries significant associated cost. As far as I can tell, the only argument for waiting is that he can choose circumcision, but viewed in context, that seems a rather weak argument.

Anonymous said...

Seriously, phimosis? I'm not going to tackle everything else, because the others have covered things pretty adequately - though you are pretty dismissive of some pretty big points.
Phimosis is not only incredibly overdiagnosed out of ignorance, but nearly always treatable by much gentler means than circumcision - more cheaply, too!

http://www.drmomma.org/2010/01/phony-phimosis-diagnosis.html

Also, let me point out that any number of minor illnesses or injuries CAN be fatal, but we don't go cutting off fingers or toes because an ingrown nail could get infected and someone may have to have surgery on it, or may eventually lose the appendage all together. Breast cancer is more likely to kill a woman, and of a higher incidence than death by UTI (AND not treatable by antibiotics I might add), yet we don't preventatively cut off breasts in infanthood!
To suggest that we cut off a foreskin, leave a permanent imprint of pain on the brain of a brand new baby, rerouting the neurological pathways of his brain, stealing from him natural protection and sensitivity for the sake of things so treatable or preventable is ludicrous.
Forgive any typing errors - I'm typing one handed in the dark as I nurse my happily intact son.

James said...

Okay, I concede infant circumcision may reduce or even eliminate balanitis and phimosis in young boys. I hasten to add that the more conventional and ethical approach to the treatment of disease is to use the least invasive method available and only to treat when disease occurs. Pre-emptive amputation of healthy living tissue is not a conventional treatment.

Beyond that, you have an opinion on the prevalence of circumcision which is up to a third higher than the (comparatively high) UN AIDS estimate.

You have an opinion that the benefit vs risk equation is so much in favour of infant circumcision that it overrides the child's human rights (right to bodily integrity), an opinion not supported by a single professional medical organisation.

I'm afraid that I cannot agree with either of your opinions on infant male circumcision.

Interesting also is that 'another' circumcision advocate /apologist named Jake does not specifically endorse forced infant circumcision over informed-consent adult circumcision either...

Jake Waskett: "I am neither in favour of or against neonatal circumcision"
http://en.wikipedia.org/wiki/User:Jakew

Jake said...

Okay, I concede infant circumcision may reduce or even eliminate balanitis and phimosis in young boys.

Good.

I hasten to add that the more conventional and ethical approach to the treatment of disease is to use the least invasive method available and only to treat when disease occurs. Pre-emptive amputation of healthy living tissue is not a conventional treatment.

It's not treatment at all; it would more correctly be described as prophylaxis.

Beyond that, you have an opinion on the prevalence of circumcision which is up to a third higher than the (comparatively high) UN AIDS estimate.

Correct.

You have an opinion that the benefit vs risk equation is so much in favour of infant circumcision that it overrides the child's human rights (right to bodily integrity), an opinion not supported by a single professional medical organisation.

Incorrect, in two ways.

Firstly, you're misrepresenting my viewpoint somewhat, I fear. I believe that circumcision does represent a net benefit, but not a huge one.

Secondly, you're misrepresenting the viewpoint of medical associations. Almost all of these share my point of view that elective circumcision is a legitimate parental choice. In the case of the AAP at least, they hold this position because of the benefits: "These potential benefits warrant a parental role in decision making about this procedure." (see here)

I'm afraid that I cannot agree with either of your opinions on infant male circumcision.

That's your right and privilege.

Interesting also is that 'another' circumcision advocate /apologist named Jake does not specifically endorse forced infant circumcision over informed-consent adult circumcision either...

No, that's me. :-)

Jake said...

To respond to Anon:

Seriously, phimosis?

Yes, it's a condition that can and does affect uncircumcised males.

I'm not going to tackle everything else, because the others have covered things pretty adequately - though you are pretty dismissive of some pretty big points.
Phimosis is not only incredibly overdiagnosed out of ignorance, but nearly always treatable by much gentler means than circumcision - more cheaply, too!

http://www.drmomma.org/2010/01/phony-phimosis-diagnosis.html


Oh my. This is a worryingly ignorant article.

Consider the following: "When a doctor diagnoses a boy with phimosis it is because he/she does not understand the normal development of the prepuce."

That statement is absolute nonsense.

Acquired phimosis can develop at any age; it's often caused by balanitis xerotica obliterans, and is characterised by the development of scar tissue at the preputial orifice, as well as the prepuce being non-retractible. It needs to be distinguished from developmental phimosis, which is normal. For example, if a boy previously had a retractible foreskin and later finds that his foreskin is no longer retractible, one can probably eliminate developmental phimosis.

But to suggest, as this author does, that boys cannot develop phimosis merely displays ignorance. Of course boys can develop phimosis: anyone, of any age, can develop phimosis!

Also, let me point out that any number of minor illnesses or injuries CAN be fatal, but we don't go cutting off fingers or toes because an ingrown nail could get infected and someone may have to have surgery on it, or may eventually lose the appendage all together.

I agree.

Breast cancer is more likely to kill a woman, and of a higher incidence than death by UTI (AND not treatable by antibiotics I might add), yet we don't preventatively cut off breasts in infanthood!

That would be fairly major surgery: I'd guess that doing so would probably be fairly hazardous.

Anonymous said...

"That would be fairly major surgery: I'd guess that doing so would probably be fairly hazardous."

Perhaps you can show us some sort of study that supports that claim? From what I have seen, double mastectomy surgery is very safe, especially since the more drastic version is hardly ever performed anymore.

"A radical mastectomy is an extensive operation where the surgeon removes the entire breast, axillary lymph nodes, and the pectoral (chest wall) muscles under the breast. This surgery was once very common. But a modified radical mastectomy has been proven to be as just as effective without the disfigurement and side effects of a radical mastectomy, so radical mastectomies are rarely done now."

"Mastectomy is very safe surgery, and most patients recover well with no complications. As with any surgery, however, there are risks. Possible complications are listed here, but keep in mind that unless stated otherwise, they usually do not happen.

The risks of any surgery are bleeding, infection, and injury to nearby tissues. Some post-operative pain and soreness is expected, but can be effectively treated with pain medication. There will also be a scar on the chest wall. Scarring occurs with all surgery, and is unavoidable.

General anesthesia risks include potential breathing and heart problems, as well possible reactions to medications. For a woman who is otherwise in good health, the risk of a serious complication due to general anesthesia is less than 1%."

http://health.nytimes.com/health/guides/surgery/mastectomy/overview.html?print=1

Jake said...

That would be fairly major surgery: I'd guess that doing so would probably be fairly hazardous."

Perhaps you can show us some sort of study that supports that claim? From what I have seen, double mastectomy surgery is very safe, especially since the more drastic version is hardly ever performed anymore.


I don't have any studies to hand, I'm afraid, and I'm not really prepared to waste my time searching for confirmation of the obvious. Compared with circumcision, dual mastectomy is fairly major, intrusive surgery, affecting a large expanse of tissue, so it is logical to expect the risk of complications to be higher.

Anonymous said...

"I don't have any studies to hand, I'm afraid, and I'm not really prepared to waste my time searching for confirmation of the obvious. Compared with circumcision, dual mastectomy is fairly major, intrusive surgery, affecting a large expanse of tissue, so it is logical to expect the risk of complications to be higher."

You may have a point if breast cancer effected roughly the same percentage of people in the United States as HIV, and if removing them only provided a 60 percent risk reduction, but that is not the case. The risks may be slightly larger, but it would ultimately save hundreds of thousands of more lives as it is a cancer that effects 12 percent of women in the United States. Removing the breasts offers up to a 99 percent risk reduction in breast cancer for every women regardless of sexual orientation or lifestyle choices.

One could even argue that the amount of tissue that is needed to remove is less on a child than on an adult, making it less invasive. Also, children heal faster right? Are these not very similar arguments that many use to advocate circumcising infants instead of adults?

Jake said...

One could even argue that the amount of tissue that is needed to remove is less on a child than on an adult, making it less invasive. Also, children heal faster right? Are these not very similar arguments that many use to advocate circumcising infants instead of adults?

If you're willing to put in the time and effort to put together data for a thorough cost-benefit analysis, I'm certainly prepared to read it with an open mind. But, I have to say, I think it likely that it will come out as a net harm.

Anonymous said...

It wouldn't matter if there was a net benefit. That is not the point. It would be unethical to permanently remove breasts from an un consenting minor without their consent. Most parents are horrified with the idea of removing the breasts of infants, because they see it as a gross violation of that infant's rights. We don't remove body parts to prevent future diseases in this country period, and foreskin should be no exception.

Jake said...

It wouldn't matter if there was a net benefit. That is not the point. It would be unethical to permanently remove breasts from an un consenting minor without their consent. Most parents are horrified with the idea of removing the breasts of infants, because they see it as a gross violation of that infant's rights. We don't remove body parts to prevent future diseases in this country period, and foreskin should be no exception.

I think it does matter. I don't think that people find the removal of body parts to be inherently offensive, but I do agree that people are horrified at the notion of dual mastectomy. I think that's because people intuitively understand that it is major surgery, that it carries both risks and harms, and that it is a net harm.

Anonymous said...

I disagree. If there was a proven net benefit, parents would still be horrified at the idea of removing breasts. Even parents of children that have tested positive for the gene that hugely increases their risk of getting breast cancer would be horrified at the idea.

Anonymous said...

Jake said:
I don't think that people find the removal of body parts to be inherently offensive, but I do agree that people are horrified at the notion of dual mastectomy. I think that's because people intuitively understand that it is major surgery, that it carries both risks and harms, and that it is a net harm.


You give sheeple too much credit here. If the masses were slowly and quietly (as is often the case with these things) given information that stated (incorrectly of course) that a preventative dual mastectomy would do X, Y and Z to improve their health and appearance, and that it was not only safe but if you do it in infanthood it won't hurt and they won't remember, it would be done. Hey, we inject tons of animal DNA, mercury, aluminum, aborted fetal tissue and other nastiness into our children at an alarming rate, don't we (well, not THIS "we," but the point stands)? It is not such a leap to suggest that if the almighty medical gods decided we should, it would be done.
Besides, the amount of the foreskin taken off in a typical circumcision (in the US) amounts to roughly (with some variation of course) 15 square inches on the adult penis. That's a lot of tissue, with 1000's of nerve endings - don't dismiss it so easily!

Jake said...

You give sheeple too much credit here. If the masses were slowly and quietly (as is often the case with these things) given information that stated (incorrectly of course) that a preventative dual mastectomy would do X, Y and Z to improve their health and appearance, and that it was not only safe but if you do it in infanthood it won't hurt and they won't remember, it would be done. Hey, we inject tons of animal DNA, mercury, aluminum, aborted fetal tissue and other nastiness into our children at an alarming rate, don't we (well, not THIS "we," but the point stands)? It is not such a leap to suggest that if the almighty medical gods decided we should, it would be done.

I think we'll have to agree to disagree on this point.

Besides, the amount of the foreskin taken off in a typical circumcision (in the US) amounts to roughly (with some variation of course) 15 square inches on the adult penis. That's a lot of tissue, with 1000's of nerve endings - don't dismiss it so easily!

That's an over-estimate. The only study in the literature to actually measure the foreskin's area reported that it is on average 36.8 square centimeters, which is 5.7 square inches. As for the number of nerve endings, no study has ever counted them.

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