Tuesday, 5 July 2011

Analysis of the Barefoot Intactivist's claims

A man calling himself the "Barefoot Intactivist" (BI from here onwards) has posted a "Response To Gordon Haber's Justification Of Child Genital Cutting".

It's predictably awful. I thought I'd share my thoughts about it.

BI begins (after a brief introduction) by complaining that:
Here we go. First Haber says I’m assuming he’s biased because he disagrees with me -- in reality, my response called him out on his bias exactly one time, in response to a specific, incredibly biased remark: Haber called the foreskin a “bit of skin.”

This is utterly irrational: the foreskin is a bit of skin, so why on earth shouldn't it be described as such? To claim that somebody is biased because they made an accurate statement is absurd.

Actually, what we call the foreskin is easily 12-15 square inches of skin (depending on where the cut is made - think the size of an index card), and it’s loaded with erogenous nerve endings.

Two claims here, so lets address each in turn. First, only one study in the literature has actually measured the surface area of the adult foreskin; it found an average surface area of 36.8 square centimetres (that's 5.7 square inches). Second, while it's true that nerve endings are present in the foreskin, it's disingenuous at best to claim that it is "loaded" with "erogenous" nerve endings: the actual number is unknown. Furthermore, no study has shown that those present are particularly erogenous in nature; in fact the only study to pose a remotely comparable research question found that the foreskin actually produced the least sexual pleasure of any part of the penis.

Before Haber even gets into my arguments he starts with ad hominem attacks, saying that I either lack “reading comprehension” or I’m “batshit crazy.” You’ll notice this tactic throughout Haber’s response, as opposed to the calm, rational tone of both his original article and my response to it.

As we shall see, the pot is calling the kettle black.

Remember, Haber allowed part of his own son’s genitals to be amputated based on the flaws in his reasoning that I exposed. So it’s perfectly normal that he would get upset when confronted with facts about the harm of genital cutting.

The mistake that BI is making here is to assume that what he has to say is "factual", and that what Haber has to say is "flawed reasoning". He is apparently unwilling to consider the notion that others might legitimately have alternative viewpoints, and for that matter that he might actually - gasp - be wrong.

Circumcision is the amputation of the foreskin of the penis. Contrary to popular belief, the foreskin is not a discrete entity, but rather a part of the contiguous penile skin system. The amount of skin cut off is entirely up to the person doing the cutting. Based on my own unscientific observation of YouTube videos online, it appears that easily around 50% of the penile skin is typically cut off in infant circumcisions (more on this later) -- sometimes significantly more, sometimes significantly less.

(At this point BI includes a still frame from a circumcision video, which he has annotated to indicate that half of the skin is being removed. Two problems here. First, the line at which he has decided the foreskin begins is his own arbitrary choice, so drawing a conclusion based upon its placement tells us more about his opinion about circumcision than about circumcision itself. Second, and more importantly, he's failed to take into account the fact that the penile skin system is extremely elastic, and the foreskin is under tension, as it is being stretched. So it should stand to reason that this will exaggerate the apparent length of the foreskin.)

Assume that the average penis is 5.9 inches long and has a circumference of 5 inches (these figures are taken from http://www.free-condom-stuff.com/education/research.htm). Further assume (for the sake of argument) that the average glans is 1 inch in length, and that the foreskin can (with assistance if necessary) fully cover the glans when erect.

Since the foreskin is a double fold, we'll count it twice. The penile skin of the penis is therefore a cylinder 5.9 + 1 + 1 = 7.9 inches long and 5 inches in circumference. This means that the surface area is 39.5 square inches.

As noted above, the adult foreskin is, on average, 5.7 square inches. 5.7 is 14% of 39.5.

(At this point BI includes a pair of videos. It's unclear what his point actually is, so I won't even try to address it.)

Regarding a study by Sorrells et al:

Haber first admits that the study, which shows that the five most “fine-touch” sensitive parts of the penis are amputated during circumcision, is “interesting,” but then he completely discards it because it was funded by NOCIRC. [para break] Nevermind that the design of the study was sound. Nevermind that it was published in the British Journal of Urology.

While the study was, unquestionably, published in BJU International, this is an extraordinarily weak argument. Weaker still is BI's claim that the design of the study was sound, for which he provides no evidence whatsoever.

In fact, despite Sorrells’ study on penile sensitivity being widely cited by critics of circumcision, there has never been a legitimate published critique of the study made by circumcision advocates. The closest was a letter written by Waskett and Morris, two notorious circumcision fetishists, neither of which have any medical credentials. (Morris is known for calling on the state to institute compulsory male infant circumcision.)

Here BI engages in ad hominem attacks against the authors of the critique (which he apparently feels either isn't legitimate or isn't published; it's unclear which). Note that, even if his claims about Prof Morris and myself were true, they still wouldn't constitute an argument against what we actually said. BI hasn't even attempted to address the substance of our critique, perhaps because we actually made some rather solid points.

But no, we should disregard Sorrells’ study because it was funded by NOCIRC. My question for Haber -- who the hell do you think is going to fund a study about the negative effects of circumcision in the U.S., the epicenter for foreskin cluelessness in the world? Who do you think NOCIRC is made up of? Does NOCIRC stand to earn profits by discouraging circumcision?

Surely it should be obvious that NOCIRC is made up of people who are opposed to circumcision, and who are extremely passionate about that? He seems to imply that because there is no financial gain to be made then NOCIRC have no reason to be biased, but that is rather short-sighted. People are willing to fly planes into skyscrapers for their beliefs, after all.

Personally, I doubt that NOCIRC would deliberately falsify their results, but I suspect that the strength of their beliefs may have blinded them to the flaws in their study, and may have influenced their dodgy interpretation.

How is this any more noteworthy a conflict then the Circumcision/HIV studies conducted by a woman (Dr. Wawer) who has built her entire reputation and career on “researching” the benefits of circumcision?

This bizarre attack against Dr Wawer is utterly unprovoked and false. Searching PubMed for articles by MJ Wawer reveals 136 results. Adding the term "circumcision" returns only 35 results; about a quarter of the total. Why make such a claim without checking the facts? It doesn't make sense.

Sorrells is a medical doctor. His study was conducted in a research university setting and published in a well known peer-reviewed medical journal. We are now four years removed from its publication, and the veracity of the study’s results have never been seriously challenged.

Actually, the results have been seriously challenged. Flatly claiming otherwise in the face of evidence to the contrary is unconvincing at best. Furthermore, the arguments in favour of the study are almost pathetically weak.

Okay, here’s another study for you. This one’s from South Korea, where circumcision has apparently taken hold after being exported by American military doctors 60 years ago. Based on a survey of 373 sexually active men, all of whom had been circumcised after the age of 20 years old [...]

Ah yes, Kim and Pang's 2006 study. Interestingly, the authors of this study attended a NOCIRC symposium in 2000, where they received a "human rights award" for their work to stamp out circumcision (see here).

It's a very poorly described study, and BI clearly hasn't read it. (Compare, for example, his above claim with the following: "The study included 373 sexually active men [...] of whom 255 were circumcised [...] and 118 were not [...]".) The study does state that "To focus on the effects of circumcision on their sexual lives, only those 138 men who could compare the quality of their sex lives including masturbation before and after circumcision were asked to complete questions 7–11, which compare the quality of sex life before and after circumcision"; however it is far from clear which results stem from which comparisons. Also unclear (in fact, completely undocumented) is the selection process, making it impossible to evaluate the study for possible biases.

More reliable results are found in RCT-based studies (one of which BI attacks below; another which can be found here.

(At this point BI announces his intention to "quickly pick apart" an RCT-based study, apparently having forgotten that it was a) it's conducted by a medical doctor, b) in a research setting, and c) published in a peer-reviewed journal.)

Unlike the Korea study, the circumcised men in this study were never asked to compare sexual pleasure before and after circumcision. In fact, the men were not asked about pleasure at all, only about desire and satisfaction.

Apparently BI has created a distinction between satisfaction and pleasure. I'm not altogether sure what that distinction is: the two seem closely related to me.

The men were only given two levels of possible satisfaction as options: “Satisfied” and “Very satisfied.”

Once again, BI appears to be attempting to criticise a study without the benefit of having read it. It is quite clear from the appendix that the possible responses were: Very satisfied, Satisfied, Dissatisfied, Very dissatisfied, No response, and Other (specify). Again, why make a claim like that without bothering to check?

Selection bias -- they are taking men who volunteered to be circumcised as adults, circumcising them, and asking them about sex afterwards. This, after telling the men that circumcision is healthy and prevents disease. Are we supposed to believe that neither the fact that the men selected themselves to be circumcised nor the fact that they were told it was a healthy, disease-preventing measure had an impact on their survey answers?

But "healthy" does not imply "better sex".

The survey was conducted two years after circumcision. What about negative sexual impacts 5, 10, 25 years later, as what’s left of the penis is left to become keratinized (calloused) through exposure to air and rubbing on clothing?

That myth has been well and truly disproven. The only study in the literature found no difference in keratinisation levels between circumcised and uncircumcised penes, and multiple studies have shown that the two are equally sensitive, even in adults circumcised as neonates.

Conflict of interest: This survey was conducted by the same team (headed by Dr. Wawer) trying to prove that circumcision prevents HIV. Establishing that the foreskin does not benefit sexual pleasure was required in order to promote the results of their HIV study.

BI is being disingenuous by implying that the researchers were seeking a predetermined outcome. In fact they were trying to determine whether circumcision protects against HIV. Science is about gathering data.

Haber completely ignores my argument (maybe it just went over his head?), which is that any negative sexual impact of circumcision is unlikely to be noticed for many years: possibly when a boy reaches puberty and starts masturbating, when he becomes sexually active, or maybe not even until many years later after the penis is fully calloused and/or damaged from excessive friction.

As noted above, this myth has been disproven.

How is a study of circumcision complications in babies addressing any of the sexual complications a circumcised man could have? Here are just a few of the possible complications that the studies Haber is referring to would never catch, because they would have to follow up 5, 10, 15, 25 years later: [...]Here is a gallery of botched circumcisions if you think I am inventing all of these

BI displays a worrying lack of logic here. Firstly, three of the speculative complications that he lists ("Tight, painful erections", "Numbness", and "Pain") couldn't be determined from a photograph. Secondly, the remaining items would be apparent in babies ("Skin bridges", "Curvature", "Twisting", and "Excessive scarring"). Thirdly, the existence of a photograph establishes that something has happened once; it doesn't provide any indication of frequency.

Answer the fucking question, Haber -- who is checking up on kids 15 years later and asking them how their dick works when they start masturbating? How many of these kids are having tight, painful erections from so much skin getting cut off? Who is checking up on 40-year old men asking them if they have any feeling left in their penises after decades of keratin build-up to the exposed glans and remnant inner foreskin?

First of all, the keratinisation claim is, as we've seen, a myth. Second, it's very unlikely that a circumcision should cause pain on erection. In fact most evidence seems to indicate that the opposite is true.

(At this point BI includes a video of a guy singing about his circumcision. Strange.)

Haber again completely avoids my point: that the foreskin isn’t just “a bit of skin” but 12-15 square inches of skin. He makes an irrelevant comparison to the total amount of skin surface area on the human body.

I'm utterly perplexed here. Even if the foreskin were that large (and it appears exaggerated by about three-fold), would that mean it wasn't a "bit"? Is there an upper size limit on "bittiness"?

The important point is that 50% (HALF) of the penile skin is being cut off.

Addressed above.

There’s actually an even more important element here. Not only is a massive amount of penile skin being removed in circumcision, but a large percentage of the most sensitive tissue, which is everything on the inside of the fold, or the “inner skin,” including specialized penile structures like the “Ridged Band” of nerve endings and the frenulum. (See Sorrells’ study above.)

The evidence does not support this claim. When properly analyses, Sorrells' study shows no differences between the foreskin and other parts of the penis. But that is sensitivity to light touch (Sorrells did not measure any of the other kinds of sensitivity), which is arguably least important to sexual pleasure, and which the foreskin (due to its innervation) would be expected to be most sensitive.

It turns out the most sensitive sexual tissue on the penis is on the inside of the foreskin

Interesting approach. Make a completely unsupported (and unsupportable) claim and prefix it with "it turns out that".

I should have been more clear here. My point was that circumcision does not work in the real world to prevent HIV. It only works in a fabricated clinical setting due to a number of flaws that call into question the validity of the results of the studies.

But they were performed by medical doctors, weren't they? In a research setting? And published in peer-reviewed journals? Gosh, is BI applying a different standard to studies depending upon whether he likes the results of a study?

I’m not going to spend a ton of time on this, because others have already done a much better job than I could hope to do.

If BI changes his mind, we can certainly analyse his arguments.

A couple of quick things to consider from these clinical trials: [...] The men who were circumcised also received counseling on condom use.

BI is being very disingenuous here. While what he says is technically correct, he's omitting the important point that both groups of men, circumcised and uncircumcised, received counselling.

The same studies also found that men who were HIV-positive were actually more likely to pass on HIV to their wives if they had been circumcised.

Wawer's study actually found no statistically significant difference.

More importantly, babies are not even sexually active.

But they do become sexually active, when they grow.

Forcing this on a non-consenting child on the other hand -- based on clinical studies that are questionable at best and contradict all available real-world data (see below)

Here BI completely misrepresents the facts. The three clinical trials were not conducted in a vacuum. They were conducted because of a series of 40 or more observational studies, from the late 1980s onwards, the majority of which showed that the risk was considerably lower among circumcised men.

The USAID data shows quite clearly that there is no real-world evidence of circumcision having any benefit whatsoever for HIV prevention on entire populations that practice it.

That's one observational study among many. Most find results consistent with the RCTs. BI has merely shown his ability to cherry-pick studies with conclusions that he likes.

Circumcision as HIV prevention just does not work in the real world. Ask the families of all the American men who died of AIDS in the 1980’s.

Here BI attacks a strawman. Nobody has claimed that circumcision completely prevents HIV; it reduces the risk. So it should be expected that a non-zero number of circumcised men will become HIV positive.

You are correct, men have penises and women have vaginas/vulvas (congratulations on recognizing this). That doesn’t mean male and female genital cutting aren’t analogous (more on this below),

One could construct an analogy with mowing the lawn (which does, after all, usually involve the use of a blade), but that doesn't mean that the analogy is particularly meaningful.

You want to know what sexism in genital cutting is? It’s when you call it “circumcision” on boys, but “mutilation” on girls, in the very same sentence.

No, that's not sexism, it's realism. FGM/C is a net harm. Circumcision isn't.

As of 1996, all forms of female genital cutting have been outlawed by federal law, down to the slightest pinprick. That means boys have no legal protection from having half or more of their penile skin removed*, despite all of the significant sexual impact and risk of further complications (see above),

But, as we've seen, BI's claims about those issues were nonsensical.

(Hilariously, BI inserts a note claiming that "Circumcision of boys is quite clearly illegal". Not according to any court decision that I've heard of.)

So congratulations, you got something right: Intactivists think people should be just as outraged by the forced genital cutting of little boys as they are with the forced genital cutting of little girls. That sounds perfectly logical to me.

I suppose it might seem logical, if one were either ignorant of the differences between the two or unwilling to learn.

(At this point BI gives a lengthy discussion of what FGC and circumcision are "all about". He offers nothing more than his opinion, so in the hope of finishing this analysis at some point I'll skip it.)

This is where even the most basic history lesson on circumcision could have saved Haber. Let’s start with religious circumcision -- nobody knows exactly how it started, but it’s very much about controlling and reducing a man’s sexuality. Famous Jewish scholar Maimonides had this to say[...]Even to Maimonides the function of the foreskin and the purpose of circumcision were obvious.

I'm skipping what Maimonides had to say, because it's completely irrelevant. Maimonides lived in the 12th century, thousands of years after circumcision began, and thus would have no way of knowing why it began. All he could do is to speculate. Similarly, scientific understanding was poorly developed in the 12th century, and Maimonides' views about the function of the foreskin are hardly authoritative.

But how did circumcision get started among non-religious people in the U.S.? Believe it or not -- it was introduced by medical doctors in the 1800’s to “cure” or reduce masturbation and excessive sex, which were believed to cause a number of diseases. This is all over the medical literature from the mid-to-late 1800’s through the mid 1900’s. Here is one particularly damning quote from a medical journal:

I wonder if BI has ever heard of the "fallacy of the striking instance"... That something is striking does not imply that it was representative or even influential. In fact, Gollaher, in his exhaustive "Circumcision: A history of the world's most controversial surgery", states that circumcision began for a quite different reason, and devotes only a handful of pages to masturbation.

(At this point, BI engages in a long and frankly bizarre digression, including an Eminem video of all things.)

So you see, YES male circumcision is performed to reduce/control male sexuality.

This is illogical. Sure, Maimonides and a handful of 19th century doctors believed that circumcision might reduce or control male sexuality, but in what way does that establish that parents today are choosing circumcision for that reason?

(At this point BI presents a list of similarities between FGC and circumcision. As I've noted above, one can easily find similarities between dissimilar things, and such a list proves little except its authors determination to write it. So I'll omit it.)

You may have different values. But to say that it is okay for one sex to be genitally cut but not the other? Pure sexism and an incredible double standard.

If it is "okay" or "not okay" because of gender, yes, that's sexism. If it's "okay" or "not okay" because of consequences, that's not inherently sexist.