Rebuttal to part 4...

Darcia Narvaez has posted part 4 of Cannon's series of articles about circumcision. Let's dive in.

No medical association in the world recommends routine infant circumcision. None.

Technically true, but routine infant circumcision means, literally, circumcision of all newborn boys. Consider what would justify such a recommendation: there would have to be an enormous net benefit to warrant taking such a decision out of the hands of parents.

In practice, most medical associations agree that the matter is suitable for parental choice.

Medicaid spends $198 million each year on routine infant circumcision in the 33 states that still pay for it, a procedure its own guidelines consider to be medically unnecessary. Private insurance programs are reimbursing an additional $677 million, raising prices for us all (Craig 2006.)

Actually, a CDC study was published in 2010 that found that "Newborn circumcision was a cost-saving HIV prevention intervention for all, black and Hispanic males". And that study considered only one benefit. If other benefits were to be considered as well, it would obviously be more cost-saving still.

Doctors have an ethical duty to treat the patient by the most conservative means possible, but removing healthy tissue in the absence of any medical need absolutely harms the patient.

By what logic? Cannon seems to think that asserting this claim is enough, but it isn't. Removal of tissue isn't inherently harmful; nor is it inherently beneficial. It can be either; to determine which the only rational approach is to look at the consequences.

Everyone has a right to bodily autonomy and self-determination. This is a fundamental tenet of international human rights law (UNESCO 2005).

Then it needs to be determined whether circumcision represents a significant violation. Human rights are not absolute, and are not intended to be read as such. Free expression, for example, does not give a person the right to libel another. Applying common sense, could it apply to something as trivial as a foreskin? It deems doubtful.

Parents' aesthetic preferences are not valid reasons for circumcision.

This statement makes sense only if one considers circumcision to be a bad thing that requires a lot of justification. But, since it is widely accepted that circumcision is harmless at worst and beneficial at best, that position seems unsupportable. Would it make sense to demand a valid reason for feeding a child a healthy diet?

If you have never had a foreskin, you cannot possibly know what having one would feel like. You only know what it feels like to not have a foreskin. You cannot know now how your son will feel in 20 or 30 years. If you have your son circumcised, he may grow up to regret the decision you made for him, but circumcision is irreversible. (Yes, men can partially restore their foreskins, but it is difficult and the sensitive nerve endings are gone forever.)

Conversely, if you don't have him circumcised, he might regret that, too. And adult circumcision is much riskier, requires a long period of abstinence, and results in inferior cosmetic results. There's no way to guarantee that he won't resent the decision, unfortunately.

Parents have a duty to educate themselves on circumcision rather than do it just because it was done to them.

For clear, easy and plain-language help making the circumcision decision, try the Circumcision Decision Maker at http://circumcisiondecisionmaker.com/.

That website recommends non-circumcision in virtually every case (the exception, as I recall, being for Orthodox Jews). If you've already decided not to circumcise and want an excuse, use it. Otherwise, it's not recommended.

Slavery and child labor were traditions sanctioned by religions and other authorities. But we abandoned those practices because they were unjust and harmful. Infant circumcision, similarly supported by authorities, should be abandoned by the people who care for children because it is unjust and harmful.

Except, of course, that it is neither unjust nor harmful. Asserting otherwise doesn't change the facts.

You were circumcised because your dad was circumcised because everyone else was circumcised because 140 years ago, some perverted doctors wanted to stop boys from masturbating.

Probably not, but I'm sure this is impressive propaganda.

Being circumcised isn't better, and it isn't popular anymore. The 70% of the world's men who have foreskins almost never choose to have them cut off and consider them to be the best part of the penis.

According to what research?

Circumcision is ending with the generation being born now - only 32% of babies born in 2009 in the USA were circumcised.

Actually, CDC data suggest that the figure is about 55%, and they caution that this is an underestimate. And, of course, rates vary greatly across the country.

Debunking myths, part 3

Cannon and Bollinger have released part 3 of their series of "myths" articles. As with previous parts, I'm analysing them here.

We'll skip the first three ("You have to circumcise the baby so that he will match his dad" and "My first son is circumcised, so I have to circumcise my second son" and "My husband is the one with the penis, so it is his choice"), since as presented they are close to myths.

Myth: Everyone is circumcised. Reality check: Actually, world-wide, only 30% of men are circumcised, and most of these men are Muslim (WHO 2007). Most modern, Westernized countries have rates well below 20%. In the United States about 25 years ago, around 85% of babies were circumcised. The rates have dropped substantially to 32% in 2009, according to a report by the Centers for Disease Control (El Becheraoui 2010).

Here the authors cite a 2010 conference presentation regarding data gathered in a survey that wasn't designed to measure circumcision rates. The New York Times quoted a CDC spokesperson as saying "we cannot comment on the accuracy of this particular estimate of infant male circumcision." Figures that the CDC have actually released are about 55%, but they caution that these underestimate the true rate.

Myth: Circumcision is an important tradition that has been going on forever. Reality check: In the United States, circumcision wasn't popularized until Victorian times, when a few doctors began to recommend it to prevent children from masturbating. Dr. Kellogg (of Corn Flakes fame) advocated circumcision for pubescent boys and girls to stop masturbation...

Ah, this old myth (and the obligatory Kellogg quote, too). No matter how striking it is, it's an error to conclude that circumcision arose because of Kellogg's recommendation. People advocate all kinds of things for all kinds of reasons. People in the late 19th century advocated circumcision for a variety of reasons, too. Gollaher, in his "Circumcision: a history of the world's most controversial surgery" devotes only a handful of pages to masturbation; he traces the history to a Lewis Sayre, who (oddly) believed circumcision could cure certain types of paralysis.

Myth: Circumcision makes sex better for the woman. and Myth: Women don't want to have sex with uncircumcised men. Reality check: In a landmark study of US women, 85% who had experienced both circumcised and intact men preferred sex with intact men.

Here the authors cite a study by O'Hara, which recruited most of the participants from an anti-circumcision mailing list, thus severely biasing the results. Credible studies, without such biases, find the opposite. See, for example, here.

Myth: "Being circumcised doesn't affect my sex life." Reality check: Men who are circumcised are 60% more likely to have difficulty identifying and expressing their feelings, which can cause marital difficulties (Bollinger 2010).

Here the authors cite an unpublished study by the second author.

Circumcised men are 4.5 times more likely to be diagnosed with erectile dysfunction, use drugs like Viagra, and to suffer from premature ejaculation (Bollinger 2010, Tang 2011).

Here the authors engage in cherry-picking. From memory, 3 studies have found increased risk of ED, 3 have found decreased risk, and six have found no statistically significant difference.

Men who were circumcised as adults experienced decreased sensation and decreased quality of erection, and both they and their partners experienced generally less satisfaction with sex (Kim 2007, Solinis 2007).

Again, the authors are engaging in cherry-picking. More studies report increased sensation than report decreased sensation, we've dealt with ED and partner satisfaction above. There is a reasonable summary of the research at Wikipedia.

Myth: "If I were any more sensitive, it would be a problem." Reality check: The foreskin contains several special structures that increase sexual pleasure, including the frenulum and ridged band (the end of the foreskin where it becomes internal), both of which are removed in circumcision. The LEAST sensitive parts of the foreskin are more sensitive than the MOST sensitive parts of the circumcised penis (Sorrells 2007).

Here the authors cite a flawed study by Sorrells et al. The authors arrived at this conclusion by testing their results for statistical significance and ignoring the result (see here). Interestingly, the authors only assessed the ability to sense the lightest touch; they did not test sensitivity to sexual stimulation. Schober et al did (admittedly with a small sample of uncircumcised men), and found that the foreskin is actually the least sexually sensitive part of the penis.

It may feel like the penis is overly sensitive to a circumcised man because there is little sensation left to indicate excitement, leading to unexpected premature ejaculation (a common problem with circumcised young men).

Actually more common among uncircumcised young men.

However, as circumcised penises age they become calloused and much less sensitive. (See the interview listed below for more details.)

Better still, see the peer-reviewed research which shows that the level of "callousing" (keratinisation) is the same in circumcised and uncircumcised men (see here), and that the glans penis is equally sensitive (see here, here, here and here).

Debunking more "myths"

Earlier today I posted a rebuttal to the first part of a "myths" article. The second part has also been posted, and is just as bad. Let's dissect it:

I'm going to skip the first two items ("You have to get the baby circumcised because it is really hard to keep a baby's penis clean" and "Little boys won't clean under their foreskins and will get infections"), because as presented they're so extreme that they almost are myths. That said, it is easier to keep a circumcised penis clean (except for the brief healing period, of course), and uncircumcised penises are more prone to infections.

Myth: Uncircumcised penises get smelly smegma. Reality check: Actually, smegma is produced by the genitals of both women and men during the reproductive years. Smegma is made of sebum and skin cells and lubricates the foreskin and glans in men, and the clitoral hood and inner labia in women. It is rinsed off during normal bathing and does not cause cancer or any other health problems.

Actually, these are rather dubious statements. A few hypotheses have been proposed, but to date no evidence supports the notion that smegma has any biological function. What little evidence there is suggests that it is associated with penile inflammation, HIV, and with penile cancer. (I should note that this evidence isn't particularly strong.) In the case of penile cancer, for example, all three of the human studies to investigate found an association between smegma and penile cancer; see here.

Myth: "My uncle wasn't circumcised and he kept getting infections and had to be circumcised as an adult." Reality check: Medical advice may have promoted infection in uncircumcised males. A shocking number of doctors are uneducated about the normal development of the foreskin, and they (incorrectly) tell parents that they have to retract the baby's foreskin and wash inside it at every diaper change. [...]

The author elaborates further on this interesting hypothesis, but utterly fails to provide any evidence whatsoever. But there's a really simple way to test it. If the difference is due to lack of knowledge about the foreskin in countries with high prevalence of circumcision, then we'd expect that studies conducted in countries with low circumcision rates wouldn't see any difference. In fact, though, the difference is observed both in the US and Canada (both of which have relatively high percentages of circumcised men) and in the UK and New Zealand (both of which have relatively low percentages of circumcised men).

Myth: My son was diagnosed with phimosis and so had to be circumcised. Reality check: Phimosis means that the foreskin will not retract. Since children's foreskins are naturally not retractable, it is impossible to diagnose phimosis in a child. Any such diagnoses in infants are based on misinformation, and are often made in order to secure insurance coverage of circumcision in states in which routine infant circumcision is no longer covered.

While an interesting conspiracy theory, there's no evidence for this. Phimosis can be diagnosed at any age, partly because acquired phimosis tends to be characterised by the presence of whitish, hard scar tissue at the tip of the foreskin. It may be overdiagnosed in children, but to claim that it cannot be diagnosed is dangerously misinformed.

Myth: Uncircumcised boys get more urinary tract infections (UTIs.) Reality check: This claim is based on one study that looked at charts of babies born in one hospital (Wiswell 1985).

Wrong. There have been about 25 studies to date. See here for a partial list.

Myth: Circumcision prevents HIV/AIDS. Reality check: Three studies in Africa several years ago that claimed that circumcision prevented AIDS and that circumcision was as effective as a 60% effective vaccine (Auvert 2005, 2006). These studies had many flaws, including that they were stopped before all the results came in. There have also been several studies that show that circumcision does not prevent HIV (Connolly 2008).

Here the author is mistakenly treating all studies as equal. They aren't. The most rigorous studies are of a type called randomised controlled trials. The most important characteristic of these studies is that circumcision is performed as part of the study, and men are selected to be circumcised at random. A less rigorous (but much cheaper) study design is to look at men who've been circumcised previously, and see whether they're HIV positive or not. This design is called an observational study, and the main problem with it is that circumcision is often associated with something else (say, religion) that's also associated with behavioural differences. So it's difficult to tell whether circumcision, or these behavioural differences, are responsible.

Of about 50 or so observational studies to date, probably 40 have found a protective effect. All three randomised controlled trials did likewise.

Debunking another "myths" article

Anti-circumcision authors seem to have a curious knack for writing articles that purportedly expose myths about circumcision while actually containing a number of incorrect statements. This is no exception. Let's dive in. (Note: I'm reformatting some of what follows for convenience.)

Myth 1: They just cut off a flap of skin. Reality check: Not true. The foreskin is half of the penis's skin, not just a flap. In an adult man, the foreskin is 15 square inches of skin. In babies and children, the foreskin is adhered to the head of the penis with the same type of tissue that adheres fingernails to their nail beds. Removing it requires shoving a blunt probe between the foreskin and the head of the penis and then cutting down and around the whole penis.

First, the average surface area of the foreskin is 36.8 square centimetres, which is 5.7 square inches not 15. Second, it's a gross exaggeration to liken the adhesions between the glans and foreskin to the nail bed. The foreskin and glans are primed to separate, and have often begun (though rarely completed) this process at birth. Separating the two is relatively trivial, requiring little force.

Myth 2: It doesn't hurt the baby. Reality check: Wrong. In 1997, doctors in Canada did a study to see what type of anesthesia was most effective in relieving the pain of circumcision. As with any study, they needed a control group that received no anesthesia. The doctors quickly realized that the babies who were not anesthetized were in so much pain that it would be unethical to continue with the study. Even the best commonly available method of pain relief studied, the dorsal penile nerve block, did not block all the babies' pain. Some of the babies in the study were in such pain that they began choking and one even had a seizure (Lander 1997).

Yes, circumcision without anaesthesia hurts. But the very study cited acknowledged that ring block was effective: "Of the 3 anesthetics considered in this investigation, ring block is clearly superior. It provides satisfactory anesthesia for all stages of the circumcision. While newborns fussed periodically over the restraints or being handled, they typically did not react to the most nociceptive elements of the circumcision (such as foreskin separation and incision)."

Myth 3: My doctor uses anesthesia. Reality check: Not necessarily. Most newborns do not receive adequate anesthesia. Only 45% of doctors who do circumcisions use any anesthesia at all. Obstetricians perform 70% of circumcisions and are least likely to use anesthesia - only 25% do. The most common reasons why they don't? They didn't think the procedure warranted it, and it takes too long (Stang 1998). A circumcision with adequate anesthesia takes a half-hour - if they brought your baby back sooner, he was in severe pain during the surgery.

The cited source (Stang and Snellman) is thirteen years old, and probably doesn't represent current practice very well. A more recent study found considerable differences in use of anaesthesia in only five years: 71% in 1998 and 97% in 2003.

Myth 4: Even if it is painful, the baby won't remember it. Reality check: The body is a historical repository and remembers everything. The pain of circumcision causes a rewiring of the baby's brain so that he is more sensitive to pain later (Taddio 1997, Anand 2000). Circumcision also can cause post-traumatic stress disorder (PTSD), depression, anger, low self-esteem and problems with intimacy (Boyle 2002, Hammond 1999, Goldman 1999). Even with a lack of explicit memory and the inability to protest - does that make it right to inflict pain? Law requires anesthesia for animal experimentation - do babies deserve any less?

There's no credible evidence that circumcision has any such long-term psychological effects. Claims to the contrary are entirely speculative, as can be seen by reading the cited sources.

Myth 5: My baby slept right through it. Reality check: Not possible without total anesthesia, which is not available. Even the dorsal penile nerve block leaves the underside of the penis receptive to pain. Babies go into shock, which though it looks like a quiet state, is actually the body's reaction to profound pain and distress. Nurses often tell the parents "He slept right through it" so as not to upset them. Who would want to hear that his or her baby was screaming in agony?

This "explanation" is amusingly contrived, but of course Occam's Razor favours the alternative explanation: that the baby actually did sleep through the procedure. This is perfectly consistent with studies of adult circumcision under anaesthesia, in which pain is reported by only a few men. For example, pain was reported by 0.83% of men in one study, and 0.2-0.3% in another.

Myth 6: It doesn't cause the baby long-term harm. Reality check: Incorrect. Removal of healthy tissue from a non-consenting patient is, in itself, harm (more on this point later). Circumcision has an array of risks and side effects. There is a 1-3% complication rate during the newborn period alone (Schwartz 1990). Here is a short list potential complications.

1-3% is a bit of an exaggeration. A recent systematic review found a median of 1.5%, but most are extremely minor.

This section continues:

Meatal Stenosis: Many circumcised boys and men suffer from meatal stenosis. This is a narrowing of the urethra which can interfere with urination and require surgery to fix.

While there's no proof, it seems likely that circumcision is a contributing factor to meatal stenosis. However, it's an exaggeration to say that "many" suffer. The largest study of circumcision and meatal stenosis found 7 cases in 66,519 circumcisions - 0.01%. The next two largest studies found risks of 0.9% (29 in 3,205) and 0.55% (11 in 2,000).

Adhesions. Circumcised babies can suffer from adhesions, where the foreskin remnants try to heal to the head of the penis in an area they are not supposed to grow on. Doctors treat these by ripping them open with no anesthesia.

As with uncircumcised boys, adhesions can occur. And, as with uncircumcised boys, they usually resolve without treatment. See this study.

(I'm skipping discussion of buried penis and infection. Both can occur, though the risk of each is small.)

Death. Babies can even die of circumcision. Over 100 newborns die each year in the USA, mostly from loss of blood and infection (Van Howe 1997 & 2004, Bollinger 2010).

This figure is wrong, as we've discussed previously.