The journal Cancer has published a new study by Wright et al., entitled "Circumcision and the risk of prostate cancer".
It's an interesting read. It's a case-control study, with 1754 cases and 1645 age-matched controls, making it by far the largest study of prostate cancer and circumcision to date. 68.8% of cases were circumcised, compared with 71.5% of controls. The risk of prostate cancer was about 13% lower among circumcised men.
Complicating the issue somewhat was the timing of circumcision, as not all men had been circumcised at birth. The fact that some circumcised men had spent some of their lives with a foreskin obviously has an impact. Indeed, in the case of penile cancer the risk is actually greater in men circumcised after childhood, likely because such circumcisions tend to be associated with conditions such as phimosis and balanitis that themselves predispose towards penile cancer.
Wisely, the researchers performed sub-analyses taking into account the timing of circumcision. They found that men circumcised before first sexual intercourse had 15% lower risk of prostate cancer. Interestingly, there was a small difference in the type of cancer: the risk reduction was 12% for less aggressive forms and 18% for more aggressive types.
While not conclusive, this study is consistent with earlier studies that also found a protective effect against circumcision. My colleagues and I previously published cost analyses on circumcision vs prostate cancer.
Tuesday, 13 March 2012
Sunday, 25 September 2011
Rebuttal to part 4...
Darcia Narvaez has posted part 4 of Cannon's series of articles about circumcision. Let's dive in.
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.
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.
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.
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.
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?
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.
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.
Except, of course, that it is neither unjust nor harmful. Asserting otherwise doesn't change the facts.
Probably not, but I'm sure this is impressive propaganda.
According to what research?
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.
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.
Sunday, 18 September 2011
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.
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.
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.
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.
Here the authors cite an unpublished study by the second author.
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.
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.
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.
Actually more common among uncircumcised young men.
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).
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).
Tuesday, 13 September 2011
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.
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.
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).
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.
Wrong. There have been about 25 studies to date. See here for a partial list.
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.
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.
Monday, 12 September 2011
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.)
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.
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)."
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.
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.
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.
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:
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).
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.)
This figure is wrong, as we've discussed previously.
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.
Thursday, 21 July 2011
Sexual satisfaction & circumcision: latest from IAS 2011
The International AIDS Society's 2011 meeting has now concluded, and — as is often the case these days — there some interesting presentations.
Of particular interest are two abstracts: Breda and Westercamp et al.
In Uganda, Breda reports on a study of 316 adult circumcision patients:
In Kenya, Westercamp et al reported on a study of 1016 adult circumcision patients:
Also, sexual dysfunctions (for two weeks or more) decreased:
And fewer penile traumas were reported (consistent with Mehta et al):
These studies add to the growing body of evidence showing that circumcision does not harm, and may well improve men's sexual experience.
As far as I can tell, neither study reports on RCT data; instead, both report on prospective study of patients circumcised as part of subsequent circumcision programmes in the same locations. Hopefully both studies will be published soon.
Of particular interest are two abstracts: Breda and Westercamp et al.
In Uganda, Breda reports on a study of 316 adult circumcision patients:
Compared to before circumcision, 87.7% (193/220) reported ease of reaching orgasm as “better”; 92.3% reported sexual satisfaction as “better”; 97.7% and 95.4% were satisfied with and thought their partners satisfied with their appearance, respectively.
In Kenya, Westercamp et al reported on a study of 1016 adult circumcision patients:
Men reported a higher overall level of satisfaction with intercourse after circumcision (71% vs. 87%, p< 0.0001). 54% of men reported their penis being much more sensitive and 36% reported reaching orgasm much more easily 6 months after circumcision.
Also, sexual dysfunctions (for two weeks or more) decreased:
inability to climax (20% vs. 16%, p=0.007), finding sex not pleasurable (31% vs. 24%, p=0.0005), and lack of interest in sex (45% vs. 39%, p=0.008).
And fewer penile traumas were reported (consistent with Mehta et al):
At 6 months, men reported experiencing fewer problems with reproductive health in the last 6 months compared to baseline: painful urination (10% before vs. 7%, p=0.008), difficulty passing urine (7% vs. 4%, p=0.01), and sores around genitals (7% vs. 4%, p=0.002). Similar reductions were found in measures of penile trauma in the preceding 6 months: pain during intercourse (15% vs. 8%, p< 0.0001); scratches, cuts, abrasions during sex (24% vs. 6%, p< 0.0001); and bleeding during or after intercourse (10% vs. 3%, p< 0.0001).
These studies add to the growing body of evidence showing that circumcision does not harm, and may well improve men's sexual experience.
As far as I can tell, neither study reports on RCT data; instead, both report on prospective study of patients circumcised as part of subsequent circumcision programmes in the same locations. Hopefully both studies will be published soon.
Tuesday, 12 July 2011
The so-called "lost list"
Although less prominent these days, I still find that people occasionally cite the "lost list", seemingly unaware of its inaccuracies. For those unfamiliar with it, this is a list of structures or functions supposedly lost through circumcision.
A number of different versions can be found on the Internet, but they're very similar. The text below is taken from NORM-UK. My comments are in italics.
The Foreskin which comprises up to 50% (sometimes more) of the mobile skin system of the penis. If unfolded and spread out flat the average adult foreskin would measure about 15 square inches( the size of a 3x5 inch index card).
This is a gross exaggeration. First, one study 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). (I previously stated that this was the only study. I was mistaken. A second study, with a small sample size, does exist. It reported an average surface area of 46.7 square centimetres, or 7.2 square inches.) Second, as I recently showed in my critique of Barefoot Intactivist's propaganda, it is reasonable to estimate that the foreskin constitutes 14% of the penile skin system. Using the surface area figure from Werker et al., that's 18% — still less than half of the extraordinary 50% figure.
This highly specialized tissue normally covers the glans and protects it from abrasion, drying, callusing (also called keratinization), and contaminants of all kinds.The effect of glans keratinisation has never been studied.
This sentence is dubious in many ways. The most obvious is the statement that the foreskin protects the glans from keratinisation — the only study in the literature to have examined keratinisation by circumcision status found no differences between the level of keratinisation of the circumcised and uncircumcised glans. Less obvious, but still troubling, is the implication that the circumcised glans is susceptible to abrasion or "contaminants". No evidence is cited in support.
[1. M. M. Lander, "The Human Prepuce," in G. C. Denniston and M. F. Milos, eds., Sexual Mutilations: A Human Tragedy (New York: Plenum Press, 1997), 79-81. 2. M. Davenport, "Problems with the Penis and Prepuce: Natural History of the Foreskin," British Medical Journal 312 (1996): 299-301.]
Note that only two sources are cited. One (Davenport) is peer-reviewed but does not support any of the claims attributed to it. The other (Lander) is a non-peer-reviewed paper presented at an anti-circumcision conference, which doesn't inspire confidence.
The Frenar Ridged Band, the primary erogenous zone of the male body.
When I see a claim like this, I immediately wonder: who established this, and what was the study methodology? The cited source (Taylor, see below) established nothing of the sort. While a small number of studies have investigated sensitivity to non-sexual stimulus, only one study, to my knowledge, has investigated the relative degree of sexual pleasure produced by various parts of the anatomy. That study (which was unfortunately limited by the small number of uncircumcised men) found that the foreskin actually produces the least sexual pleasure of any part of the penis.
Loss of this delicate belt of densely innervated, sexually responsive tissue reduces the fullness and intensity of sexual response.
[Taylor, J. R. et al., "The Prepuce: Specialized Mucosa of the Penis and Its Loss to Circumcision," British Journal of Urology 77 (1996): 291-295.]
Note that the cited source says nothing of the sort! Its authors merely "postulate" that the "ridged band" is sensory tissue. They don't attempt to prove it, nor do they evaluate the effects of its removal on the "fullness and intensity" of sexual response.
The Foreskin's 'Gliding Action' - the hallmark mechanical feature of the normal natural, intact penis. This non-abrasive gliding of the penis in and out of itself within the vagina facilitates smooth , comfortable, pleasurable intercourse for both partners. Without this gliding action, the corona of the circumcised penis can function as a oneway valve, scraping vaginal lubricants out into the drying air and making artificial lubricants essential for pleasurable intercourse.
[P. M. Fleiss, MD, MPH, "The Case Against Circumcision," Mothering: The Magazine of Natural Family Living (Winter 1997): 36-45.]
Note that the only source cited for this claim is an opinion piece published in a magazine. It's an interesting hypothesis, but little or no credible evidence supports it.
[Indented box] Nerve Endings transmit Sensations to the Brain - Fewer Nerve Endings means Fewer Sensations
This simplistic model is faulty because the presence of nerve endings do not create sensations by themselves. Likely as not, your genitals are not buzzing with sensations as you read this, because they're not being stimulated. This means that the method and degree of stimulation is as important as the number of nerve endings. Put simply, a smaller number of nerve endings can produce just as much stimulation as a larger number, if stimulated more effectively. And this is effectively what circumcision achieves, by exposing the glans (especially the sensitive corona) to direct stimulation during intercourse, sensation is increased, compensating for the loss of sensation from the foreskin itself.
Circumcision removes the most important sensory component of the foreskin - thousands of coiled fine-touch receptors called Meissner's corpuscles.
Most important? Who established this, and what was the study methodology?
Also lost are branches of the dorsal nerve, and between 10,000 and 20,000 specialized erotogenic nerve endings of several types.
What is the source for this number? Neither of the two cited sources support it. In fact, having researched this in some depth, I feel quite confident in stating that no study has ever counted the number of nerve endings in the foreskin.
Together these detect subtle changes in motion and temperature, as well as fine gradations in texture.
[1. R. K. Winkelmann, "The Erogenous Zones: Their Nerve Supply and Its Significance," Proceedings of the Staff Meetings of the Mayo Clinic 34 (1959): 39-47. 2. R. K. Winkelmann, "The Cutaneous Innervation of Human Newborn Prepuce," Journal of Investigative Dermatology 26 (1956): 53-67.]
Again, the sources fail to support the claims attributed to them.
The Frenulum[.] The highly erogenous V-shaped web-like tethering structure on the underside of the glans; frequently amputated along with the foreskin, or severed, either of which destroys its function and potential for pleasure.
[1. Cold, C, Taylor, J, "The Prepuce," BJU International 83, Suppl. 1, (1999): 34-44. 2. Kaplan, G.W., "Complications of Circumcision," Urologic Clinics of North America 10, 1983.]
Neither of the cited sources actually supports these claims. This isn't terribly surprising because a) the frenulum's potential for pleasure is speculative, and b) the function of the frenulum, such as it is, is to hold the foreskin in place over the glans. Without a foreskin, then, it has no function.
Muscle Sheath[.] Circumcision removes approximately half of the temperature-sensitive smooth muscle sheath which lies between the outer layer of skin and the corpus cavernosa. This is called the dartos fascia.
[Netter, F.H., "Atlas of Human Anatomy," Second Edition (Novartis, 1997): Plates 234, 329, 338, 354, 355.]
"Approximately half" is of course an exaggeration, but it is true that the foreskin does contain this layer.
The Immunological Defense System of the soft mucosa. This produces both plasma cells that secrete immunoglobulin antibodies and antibacterial and antiviral proteins such as the pathogen-killing enzyme lysozyme.
[1. A. Ahmed and A. W. Jones, "Apocrine Cystadenoma: A Report of Two Cases Occurring on the Prepuce," British Journal of Dermatology 81 (1969): 899-901. 2. P. J. Flower et al., "An Immunopathologic Study of the Bovine Prepuce," Veterinary Pathology 20 (1983):189-202.]
The cited sources utterly fail to support these claims. The second is not even a study of the human prepuce, but rather that of the cow! While the foreskin doubtless contains the immunological functions of any skin, no special mechanisms are known.
Lymphatic Vessels[.] the loss of which reduces the lymph flow within that part of the body's immune system.
[Netter, F.H., "Atlas of Human Anatomy," Second Edition (Novartis, 1997): plate 379.]
This is really scraping the bottom of the barrel, but yes, removing skin does remove the lymph vessels within it.
Oestrogen Receptors The presence of estrogen receptors within the foreskin has only recently been discovered. Their purpose is not yet understood and needs further study.
[R. Hausmann et al., "The Forensic Value of the Immunohistochemical Detection of Oestrogen Receptors in Vaginal Epithelium," International Journal of Legal Medicine 109 (1996): 10-30.]
If confirmed, for that matter.
[Indented box] The Body is Well Designed - Altering it Surgically can only Disrupt it's Natural Function
This is more a statement of faith than a serious claim, but we can transform it into a scientifically testable hypothesis: surgical alteration of the body cannot produce positive effects. It seems almost trivial to show that it is false.
The Apocrine Glands of the inner foreskin, which produce pheremones -nature's powerful, silent, invisible behavioural signals to potential sexual partners. The effect of their absence on human sexuality has never been studied.
[A. Ahmed and A. W. Jones, "Apocrine Cystadenoma: A Report of Two Cases Occurring on the Prepuce," British Journal of Dermatology 81 (1969): 899-901.]
A serious problem with this claim is that apocrine glands are absent in the inner foreskin. Amusingly, one of the sources cited above (Taylor et al) says this: "the mucosal surface of the prepuce is completely free of lanugo hair follicles, sweat and sebaceous glands". Similarly, Parkash et al report: "Multiple small pieces were taken from the inner lining of the circumcised prepuce [...] A special search was made for glandular tissue. No such tissue was found in the material".
Sebaceous Glands which lubricate and moisturise the foreskin and glans, normally a protected and internal organ-like the tongue or vagina. Not all men have sebaceous glands on their inner foreskin.
[A. B. Hyman and M. H. Brownstein, "Tyson's Glands: Ectopic Sebaceous Glands and Papillomatosis Penis," Archives of Dermatology 99 (1969): 31-37.]
In fact, according to the studies cited above, no men have sebaceous glands on their inner foreskin.
Langerhans Cells Specialised epithelial Langerhans cells, a first line component of the body's immune system in a whole penis.
[G. N. Weiss et al., "The Distribution and Density of Langerhans Cells in the Human Prepuce: Site of a Diminished Immune Response?" Israel Journal of Medical Sciences 29 (1993): 42-43.]
The cited source actually states the opposite: that the foreskin is deficient in Langerhans cells.
Colouration[.] The natural coloration of the glans and inner foreskin (usually hidden and only visible to others when sexually aroused) is considerably more intense than the permanently exposed and keratinized coloration of a circumcised penis. The socio-biological function of this visual stimulus has never been studied.
Ignoring the keratinisation error, this seems to be rather desperate. The appearance of the penis is changed, so this is a loss?
Some of the penis length and circumference because its double-layered wrapping of loose and usually overhanging foreskin is now missing, making the circumcised penis truncated and thinner than it would have been if left intact.
An Australian survey in 1995 showed circumcised men to have erect penises an average of 8mm shorter than intact men.
[1. R. D. Talarico and J. E. Jasaitis, "Concealed Penis: A Complication of Neonatal Circumcision," Journal of Urology 110 (1973): 732-733. 2. Richters J, Gerofi J, Donovan B. Why do condoms break or slip off in use? An exploratory study. Int J STD AIDS. 1995; 6(1):11-8. ]
It should be noted that this Australian study is in fact the only study to report such a difference.
Blood Vessels[.] Several feet of blood vessels, including the frenular artery and branches of the dorsal artery are removed in circumcision. This loss of the rich vascularity interrupts normal flow to the shaft and glans of the penis, damaging the the natural function of the penis and altering its development. [1. H. C. Bazett et al., "Depth, Distribution and Probable Identification in the Prepuce of Sensory End-Organs Concerned in Sensations of Temperature and Touch; Thermometric Conductivity," Archives of Neurology and Psychiatry 27 (1932): 489-517.� 2. Netter, F.H., "Atlas of Human Anatomy," Second Edition (Novartis, 1997): plates 238, 239.]
It is quite likely that several feet are lost, as the human body has an extraordinary number of blood vessels (a typical estimate is that the adult human body contains 100,000 miles of blood vessels). The claimed consequences, however, are unsupported by the references cited.
Dorsal Nerves The terminal branch of the pudendal nerve connects to the skin of the penis, the prepuce, the corpora cavernosa, and the glans. Destruction of these nerves is a rare but devastating complication of circumcision. If cut during circumcision, the top two-thirds of the penis will be almost completely without sensation. [1. Agur, A.M.R. ed., "Grant's Atlas of Anatomy," Ninth Edition (Williams and Wilkins, 1991): 188-190. 2. Netter, F.H., "Atlas of Human Anatomy," Second Edition (Novartis, 1997): plate 380, 387.]
One wonders why such extremely rare, albeit possible complications are included, then. To pad out the list, perhaps?
Complications Every year boys lose their entire penises from circumcision accidents and infection. They are then "sexually reassigned" by castration and "transgender surgery" and expected to live their lives as "females". [1. J. P. Gearhart and J. A. Rock, "Total Ablation of the Penis after Circumcision with Electrocautery: A Method of Management and Long-Term Followup," Journal of Urology 142 (1989):799-801. 2. M. Diamond and H. K. Sigmundson, "Sex Reassignment at Birth: Long-Term Review and Clinical Implications," Archives of Pediatrics and Adolescent Medicine 151 (1997): 298-304.]
It may be an exaggeration to claim that this happens "every year", but cases have been reported, unfortunately.
Death Every year many boys lose their lives from the complications of circumcision, a fact the billion-dollar-a-year circumcision industry in the U.S. routinely obscures and ignores.
[1. G. W. Kaplan, "Complications of Circumcision," Urologic Clinics of North America 10 (1983): 543-549. 2. R. S. Thompson, "Routine Circumcision in the Newborn: An Opposing View," Journal of Family Practice 31 (1990): 189-196.]
Again, death does occur, albeit rarely. However, it would be foolish to consider such deaths in isolation. They should be weighed against deaths attributable to lack of circumcision. That is, if a million boys are circumcised, does this result in more or fewer deaths than if those boys are not circumcised. The evidence indicates that lives are saved.
Emotional Bonding[.] Circumcision performed during infancy disrupts the bonding process between child and mother. There are indications that the innate sense of trust in intimate human contact is inhibited or lost.
Who established this, and what was the study methodology?
It can also have significant adverse effects on neurological development. Additionally, an infant's self-confidence and hardiness is diminished by forcing the newborn victim into a defensive psychological state of "learned helplessness" or "acquired passivity" to cope with the excruciating pain which he can neither fight nor flee.
Who established this, and what was the study methodology? (How on Earth would one be able to prove such a thing? It looks suspiciously like an unfalsifiable statement: a product of pseudoscience, not science.
The trauma of this early pain lowers a circumcised boy's pain threshold below that of intact boys and girls. [1. R. Goldman, Circumcision: The Hidden Trauma (Boston: Vanguard Publications, 1997), 139-175. 2. A. Taddio et al., "Effect of Neonatal Circumcision on Pain Responses during Vaccination in Boys," Lancet 345 (1995): 291-292.]
Neurological Sexual Communication[.] Although never studied scientifically, contemporary evidence suggests that a penis without its foreskin lacks the capacity for the subtle neurological "cross-communication" that occurs only during contact between mucous membranes and which contributes to the experience of sexual pleasure.
What utter nonsense! How on earth would non-scientific evidence suggest such a thing? This appears to be nothing more than a wild theory, dishonestly presented as something suggested by evidence.
Amputating an infant boy's multi-functional foreskin is a "low-grade neurological castration" [Immerman], which diminishes the intensity of the entire sexual experience for both the circumcised male and his partner.)
So prove it. Should be trivial. Except, of course, that scientific studies of satisfaction, etc., don't support this claim.
A number of different versions can be found on the Internet, but they're very similar. The text below is taken from NORM-UK. My comments are in italics.
The Foreskin which comprises up to 50% (sometimes more) of the mobile skin system of the penis. If unfolded and spread out flat the average adult foreskin would measure about 15 square inches( the size of a 3x5 inch index card).
This is a gross exaggeration. First, one study 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). (I previously stated that this was the only study. I was mistaken. A second study, with a small sample size, does exist. It reported an average surface area of 46.7 square centimetres, or 7.2 square inches.) Second, as I recently showed in my critique of Barefoot Intactivist's propaganda, it is reasonable to estimate that the foreskin constitutes 14% of the penile skin system. Using the surface area figure from Werker et al., that's 18% — still less than half of the extraordinary 50% figure.
This highly specialized tissue normally covers the glans and protects it from abrasion, drying, callusing (also called keratinization), and contaminants of all kinds.The effect of glans keratinisation has never been studied.
This sentence is dubious in many ways. The most obvious is the statement that the foreskin protects the glans from keratinisation — the only study in the literature to have examined keratinisation by circumcision status found no differences between the level of keratinisation of the circumcised and uncircumcised glans. Less obvious, but still troubling, is the implication that the circumcised glans is susceptible to abrasion or "contaminants". No evidence is cited in support.
[1. M. M. Lander, "The Human Prepuce," in G. C. Denniston and M. F. Milos, eds., Sexual Mutilations: A Human Tragedy (New York: Plenum Press, 1997), 79-81. 2. M. Davenport, "Problems with the Penis and Prepuce: Natural History of the Foreskin," British Medical Journal 312 (1996): 299-301.]
Note that only two sources are cited. One (Davenport) is peer-reviewed but does not support any of the claims attributed to it. The other (Lander) is a non-peer-reviewed paper presented at an anti-circumcision conference, which doesn't inspire confidence.
The Frenar Ridged Band, the primary erogenous zone of the male body.
When I see a claim like this, I immediately wonder: who established this, and what was the study methodology? The cited source (Taylor, see below) established nothing of the sort. While a small number of studies have investigated sensitivity to non-sexual stimulus, only one study, to my knowledge, has investigated the relative degree of sexual pleasure produced by various parts of the anatomy. That study (which was unfortunately limited by the small number of uncircumcised men) found that the foreskin actually produces the least sexual pleasure of any part of the penis.
Loss of this delicate belt of densely innervated, sexually responsive tissue reduces the fullness and intensity of sexual response.
[Taylor, J. R. et al., "The Prepuce: Specialized Mucosa of the Penis and Its Loss to Circumcision," British Journal of Urology 77 (1996): 291-295.]
Note that the cited source says nothing of the sort! Its authors merely "postulate" that the "ridged band" is sensory tissue. They don't attempt to prove it, nor do they evaluate the effects of its removal on the "fullness and intensity" of sexual response.
The Foreskin's 'Gliding Action' - the hallmark mechanical feature of the normal natural, intact penis. This non-abrasive gliding of the penis in and out of itself within the vagina facilitates smooth , comfortable, pleasurable intercourse for both partners. Without this gliding action, the corona of the circumcised penis can function as a oneway valve, scraping vaginal lubricants out into the drying air and making artificial lubricants essential for pleasurable intercourse.
[P. M. Fleiss, MD, MPH, "The Case Against Circumcision," Mothering: The Magazine of Natural Family Living (Winter 1997): 36-45.]
Note that the only source cited for this claim is an opinion piece published in a magazine. It's an interesting hypothesis, but little or no credible evidence supports it.
[Indented box] Nerve Endings transmit Sensations to the Brain - Fewer Nerve Endings means Fewer Sensations
This simplistic model is faulty because the presence of nerve endings do not create sensations by themselves. Likely as not, your genitals are not buzzing with sensations as you read this, because they're not being stimulated. This means that the method and degree of stimulation is as important as the number of nerve endings. Put simply, a smaller number of nerve endings can produce just as much stimulation as a larger number, if stimulated more effectively. And this is effectively what circumcision achieves, by exposing the glans (especially the sensitive corona) to direct stimulation during intercourse, sensation is increased, compensating for the loss of sensation from the foreskin itself.
Circumcision removes the most important sensory component of the foreskin - thousands of coiled fine-touch receptors called Meissner's corpuscles.
Most important? Who established this, and what was the study methodology?
Also lost are branches of the dorsal nerve, and between 10,000 and 20,000 specialized erotogenic nerve endings of several types.
What is the source for this number? Neither of the two cited sources support it. In fact, having researched this in some depth, I feel quite confident in stating that no study has ever counted the number of nerve endings in the foreskin.
Together these detect subtle changes in motion and temperature, as well as fine gradations in texture.
[1. R. K. Winkelmann, "The Erogenous Zones: Their Nerve Supply and Its Significance," Proceedings of the Staff Meetings of the Mayo Clinic 34 (1959): 39-47. 2. R. K. Winkelmann, "The Cutaneous Innervation of Human Newborn Prepuce," Journal of Investigative Dermatology 26 (1956): 53-67.]
Again, the sources fail to support the claims attributed to them.
The Frenulum[.] The highly erogenous V-shaped web-like tethering structure on the underside of the glans; frequently amputated along with the foreskin, or severed, either of which destroys its function and potential for pleasure.
[1. Cold, C, Taylor, J, "The Prepuce," BJU International 83, Suppl. 1, (1999): 34-44. 2. Kaplan, G.W., "Complications of Circumcision," Urologic Clinics of North America 10, 1983.]
Neither of the cited sources actually supports these claims. This isn't terribly surprising because a) the frenulum's potential for pleasure is speculative, and b) the function of the frenulum, such as it is, is to hold the foreskin in place over the glans. Without a foreskin, then, it has no function.
Muscle Sheath[.] Circumcision removes approximately half of the temperature-sensitive smooth muscle sheath which lies between the outer layer of skin and the corpus cavernosa. This is called the dartos fascia.
[Netter, F.H., "Atlas of Human Anatomy," Second Edition (Novartis, 1997): Plates 234, 329, 338, 354, 355.]
"Approximately half" is of course an exaggeration, but it is true that the foreskin does contain this layer.
The Immunological Defense System of the soft mucosa. This produces both plasma cells that secrete immunoglobulin antibodies and antibacterial and antiviral proteins such as the pathogen-killing enzyme lysozyme.
[1. A. Ahmed and A. W. Jones, "Apocrine Cystadenoma: A Report of Two Cases Occurring on the Prepuce," British Journal of Dermatology 81 (1969): 899-901. 2. P. J. Flower et al., "An Immunopathologic Study of the Bovine Prepuce," Veterinary Pathology 20 (1983):189-202.]
The cited sources utterly fail to support these claims. The second is not even a study of the human prepuce, but rather that of the cow! While the foreskin doubtless contains the immunological functions of any skin, no special mechanisms are known.
Lymphatic Vessels[.] the loss of which reduces the lymph flow within that part of the body's immune system.
[Netter, F.H., "Atlas of Human Anatomy," Second Edition (Novartis, 1997): plate 379.]
This is really scraping the bottom of the barrel, but yes, removing skin does remove the lymph vessels within it.
Oestrogen Receptors The presence of estrogen receptors within the foreskin has only recently been discovered. Their purpose is not yet understood and needs further study.
[R. Hausmann et al., "The Forensic Value of the Immunohistochemical Detection of Oestrogen Receptors in Vaginal Epithelium," International Journal of Legal Medicine 109 (1996): 10-30.]
If confirmed, for that matter.
[Indented box] The Body is Well Designed - Altering it Surgically can only Disrupt it's Natural Function
This is more a statement of faith than a serious claim, but we can transform it into a scientifically testable hypothesis: surgical alteration of the body cannot produce positive effects. It seems almost trivial to show that it is false.
The Apocrine Glands of the inner foreskin, which produce pheremones -nature's powerful, silent, invisible behavioural signals to potential sexual partners. The effect of their absence on human sexuality has never been studied.
[A. Ahmed and A. W. Jones, "Apocrine Cystadenoma: A Report of Two Cases Occurring on the Prepuce," British Journal of Dermatology 81 (1969): 899-901.]
A serious problem with this claim is that apocrine glands are absent in the inner foreskin. Amusingly, one of the sources cited above (Taylor et al) says this: "the mucosal surface of the prepuce is completely free of lanugo hair follicles, sweat and sebaceous glands". Similarly, Parkash et al report: "Multiple small pieces were taken from the inner lining of the circumcised prepuce [...] A special search was made for glandular tissue. No such tissue was found in the material".
Sebaceous Glands which lubricate and moisturise the foreskin and glans, normally a protected and internal organ-like the tongue or vagina. Not all men have sebaceous glands on their inner foreskin.
[A. B. Hyman and M. H. Brownstein, "Tyson's Glands: Ectopic Sebaceous Glands and Papillomatosis Penis," Archives of Dermatology 99 (1969): 31-37.]
In fact, according to the studies cited above, no men have sebaceous glands on their inner foreskin.
Langerhans Cells Specialised epithelial Langerhans cells, a first line component of the body's immune system in a whole penis.
[G. N. Weiss et al., "The Distribution and Density of Langerhans Cells in the Human Prepuce: Site of a Diminished Immune Response?" Israel Journal of Medical Sciences 29 (1993): 42-43.]
The cited source actually states the opposite: that the foreskin is deficient in Langerhans cells.
Colouration[.] The natural coloration of the glans and inner foreskin (usually hidden and only visible to others when sexually aroused) is considerably more intense than the permanently exposed and keratinized coloration of a circumcised penis. The socio-biological function of this visual stimulus has never been studied.
Ignoring the keratinisation error, this seems to be rather desperate. The appearance of the penis is changed, so this is a loss?
Some of the penis length and circumference because its double-layered wrapping of loose and usually overhanging foreskin is now missing, making the circumcised penis truncated and thinner than it would have been if left intact.
An Australian survey in 1995 showed circumcised men to have erect penises an average of 8mm shorter than intact men.
[1. R. D. Talarico and J. E. Jasaitis, "Concealed Penis: A Complication of Neonatal Circumcision," Journal of Urology 110 (1973): 732-733. 2. Richters J, Gerofi J, Donovan B. Why do condoms break or slip off in use? An exploratory study. Int J STD AIDS. 1995; 6(1):11-8. ]
It should be noted that this Australian study is in fact the only study to report such a difference.
Blood Vessels[.] Several feet of blood vessels, including the frenular artery and branches of the dorsal artery are removed in circumcision. This loss of the rich vascularity interrupts normal flow to the shaft and glans of the penis, damaging the the natural function of the penis and altering its development. [1. H. C. Bazett et al., "Depth, Distribution and Probable Identification in the Prepuce of Sensory End-Organs Concerned in Sensations of Temperature and Touch; Thermometric Conductivity," Archives of Neurology and Psychiatry 27 (1932): 489-517.� 2. Netter, F.H., "Atlas of Human Anatomy," Second Edition (Novartis, 1997): plates 238, 239.]
It is quite likely that several feet are lost, as the human body has an extraordinary number of blood vessels (a typical estimate is that the adult human body contains 100,000 miles of blood vessels). The claimed consequences, however, are unsupported by the references cited.
Dorsal Nerves The terminal branch of the pudendal nerve connects to the skin of the penis, the prepuce, the corpora cavernosa, and the glans. Destruction of these nerves is a rare but devastating complication of circumcision. If cut during circumcision, the top two-thirds of the penis will be almost completely without sensation. [1. Agur, A.M.R. ed., "Grant's Atlas of Anatomy," Ninth Edition (Williams and Wilkins, 1991): 188-190. 2. Netter, F.H., "Atlas of Human Anatomy," Second Edition (Novartis, 1997): plate 380, 387.]
One wonders why such extremely rare, albeit possible complications are included, then. To pad out the list, perhaps?
Complications Every year boys lose their entire penises from circumcision accidents and infection. They are then "sexually reassigned" by castration and "transgender surgery" and expected to live their lives as "females". [1. J. P. Gearhart and J. A. Rock, "Total Ablation of the Penis after Circumcision with Electrocautery: A Method of Management and Long-Term Followup," Journal of Urology 142 (1989):799-801. 2. M. Diamond and H. K. Sigmundson, "Sex Reassignment at Birth: Long-Term Review and Clinical Implications," Archives of Pediatrics and Adolescent Medicine 151 (1997): 298-304.]
It may be an exaggeration to claim that this happens "every year", but cases have been reported, unfortunately.
Death Every year many boys lose their lives from the complications of circumcision, a fact the billion-dollar-a-year circumcision industry in the U.S. routinely obscures and ignores.
[1. G. W. Kaplan, "Complications of Circumcision," Urologic Clinics of North America 10 (1983): 543-549. 2. R. S. Thompson, "Routine Circumcision in the Newborn: An Opposing View," Journal of Family Practice 31 (1990): 189-196.]
Again, death does occur, albeit rarely. However, it would be foolish to consider such deaths in isolation. They should be weighed against deaths attributable to lack of circumcision. That is, if a million boys are circumcised, does this result in more or fewer deaths than if those boys are not circumcised. The evidence indicates that lives are saved.
Emotional Bonding[.] Circumcision performed during infancy disrupts the bonding process between child and mother. There are indications that the innate sense of trust in intimate human contact is inhibited or lost.
Who established this, and what was the study methodology?
It can also have significant adverse effects on neurological development. Additionally, an infant's self-confidence and hardiness is diminished by forcing the newborn victim into a defensive psychological state of "learned helplessness" or "acquired passivity" to cope with the excruciating pain which he can neither fight nor flee.
Who established this, and what was the study methodology? (How on Earth would one be able to prove such a thing? It looks suspiciously like an unfalsifiable statement: a product of pseudoscience, not science.
The trauma of this early pain lowers a circumcised boy's pain threshold below that of intact boys and girls. [1. R. Goldman, Circumcision: The Hidden Trauma (Boston: Vanguard Publications, 1997), 139-175. 2. A. Taddio et al., "Effect of Neonatal Circumcision on Pain Responses during Vaccination in Boys," Lancet 345 (1995): 291-292.]
Neurological Sexual Communication[.] Although never studied scientifically, contemporary evidence suggests that a penis without its foreskin lacks the capacity for the subtle neurological "cross-communication" that occurs only during contact between mucous membranes and which contributes to the experience of sexual pleasure.
What utter nonsense! How on earth would non-scientific evidence suggest such a thing? This appears to be nothing more than a wild theory, dishonestly presented as something suggested by evidence.
Amputating an infant boy's multi-functional foreskin is a "low-grade neurological castration" [Immerman], which diminishes the intensity of the entire sexual experience for both the circumcised male and his partner.)
So prove it. Should be trivial. Except, of course, that scientific studies of satisfaction, etc., don't support this claim.
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:
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.
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.
As we shall see, the pot is calling the kettle black.
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.
(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:
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.
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.
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.
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.
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.
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.)
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.
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?
But "healthy" does not imply "better sex".
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.
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.
As noted above, this myth has been disproven.
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.
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.)
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"?
Addressed 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.
Interesting approach. Make a completely unsupported (and unsupportable) claim and prefix it with "it turns out that".
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?
If BI changes his mind, we can certainly analyse his arguments.
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.
Wawer's study actually found no statistically significant difference.
But they do become sexually active, when they grow.
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.
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.
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.
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.
No, that's not sexism, it's realism. FGM/C is a net harm. Circumcision isn't.
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.)
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.)
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.
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.)
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.)
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.
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.
Sunday, 27 February 2011
Phimosis, redundant prepuce, and mental health
Just a short post.
An interesting new study by Yang et al. reveals news that shouldn't be terribly surprising: "Patients with redundant prepuce or phimosis have poor mental health, and there is an interaction between PE [premature ejaculation] and the mental state of the patient."
As I said, this shouldn't be terribly surprising. But it does make one wonder about the degree to which prophylactic circumcision might prevent this suffering, especially as phimosis is not uncommon. I'm not saying that widespread circumcision would be justified on this basis alone, but clearly it should be incorporated into cost-benefit models.
An interesting new study by Yang et al. reveals news that shouldn't be terribly surprising: "Patients with redundant prepuce or phimosis have poor mental health, and there is an interaction between PE [premature ejaculation] and the mental state of the patient."
As I said, this shouldn't be terribly surprising. But it does make one wonder about the degree to which prophylactic circumcision might prevent this suffering, especially as phimosis is not uncommon. I'm not saying that widespread circumcision would be justified on this basis alone, but clearly it should be incorporated into cost-benefit models.
Thursday, 13 January 2011
The penis and sexual pleasure
Now this is an interesting study: "Self-ratings of genital anatomy, sexual sensitivity and function in men using the 'Self-Assessment of Genital Anatomy and Sexual Function, Male' questionnaire" (PDF).
It's a study of self-assessed ratings of sexual pleasure, orgasm intensity, and similar items by area. The study included 81 healthy men. One weakness of the study was that only eleven men were uncircumcised; this shouldn't bias the results, but it does mean that the foreskin's scores are known with less precision than those for other areas.
The key results were as follows:
What this means, effectively, is that the foreskin is the least sensitive of all areas of the penis, when "sensitive" is defined as "capable of producing sexual pleasure or orgasm".
This is no great surprise to me. It's entirely consistent with the bulk of evidence indicating that the foreskin can be removed without adverse effects on sexual satisfaction, which would seem inconsistent with the foreskin playing a major role in sexual pleasure. But it may come as a surprise to those who were mislead by studies such as Sorrells et al., which (erroneously) presented the foreskin as the most sensitive part of the penis. Why?
Well, as Prof. Morris and I noted (among other points) in our critique of Sorrells' paper:
Put bluntly, the two studies measured completely different things. Sorrells et al tested response to having a nylon filament pressed against the skin; Schober assessed response to sexual stimulation. And the two are not the same at all.
It's a study of self-assessed ratings of sexual pleasure, orgasm intensity, and similar items by area. The study included 81 healthy men. One weakness of the study was that only eleven men were uncircumcised; this shouldn't bias the results, but it does mean that the foreskin's scores are known with less precision than those for other areas.
The key results were as follows:
Overall discrimination between genital areas was highly significant (mixed-model anova, P = 0.001) for ratings of 'sexual pleasure', 'orgasm intensity' and 'orgasm effort', but was not significant for 'discomfort/pain'. Ranked by degree of 'sexual pleasure', the area 'underside of the glans' was highest, followed by 'underside of the penile shaft', 'upper side of the glans', 'left and right sides of the glans', 'one or both sides of the penis', 'upper side of the penile shaft', 'foreskin' (11 subjects), 'skin between the scrotum and anus', 'back side of the scrotum', 'front side of the scrotum', and 'around anus', but not all pair differences were significant. The rank order was similar for 'orgasm intensity', but less similar and with fewer significant pair differences for 'orgasm effort'.
What this means, effectively, is that the foreskin is the least sensitive of all areas of the penis, when "sensitive" is defined as "capable of producing sexual pleasure or orgasm".
This is no great surprise to me. It's entirely consistent with the bulk of evidence indicating that the foreskin can be removed without adverse effects on sexual satisfaction, which would seem inconsistent with the foreskin playing a major role in sexual pleasure. But it may come as a surprise to those who were mislead by studies such as Sorrells et al., which (erroneously) presented the foreskin as the most sensitive part of the penis. Why?
Well, as Prof. Morris and I noted (among other points) in our critique of Sorrells' paper:
The authors conclude that ‘circumcision ablates the most sensitive parts of the penis’, although they only tested the ability of subjects to detect the lightest touch. Meissner’s corpuscles, being light-touch receptors, would be expected to cause such a measurement to exaggerate the sensitivity of the prepuce. However, sensitivity, particularly when discussing erogenous sensation, depends on several different modes of stimulation and their interaction. In addition, sexual sensation depends upon the types of mechanical stimulation generated during intercourse, which might in turn be influenced by circumcision status. Thus circumcision has the potential to either increase or decrease sexual sensation.
Put bluntly, the two studies measured completely different things. Sorrells et al tested response to having a nylon filament pressed against the skin; Schober assessed response to sexual stimulation. And the two are not the same at all.
Wednesday, 12 January 2011
Circumcision, HPV, and HIV
After a period of relative quiet, I found two interesting new studies in my PubMed alert this morning.
First, Wawer et al. published Effect of circumcision of HIV-negative men on transmission of human papillomavirus to HIV-negative women: a randomised trial in Rakai, Uganda. This is a fascinating study, not least because it is yet another study cleverly piggy-backed on one of the randomised controlled trials that effectively proved that circumcision reduces the risk of HIV. Results have been published previously showing that circumcision reduced the risk of (and increased clearance of) HPV infection in men; what's unusual about this study is that it directly measured the effect on infection in women (to be precise, the female partners of the men in the trial). And as previous observational studies indicated, the risk was reduced, from 38.7% to 27.8%.
The significance of this, of course, is that HPV is the virus responsible for cervical cancer in women (and about half of penile cancers in men). According to the World Health Organisation, cervical cancer is the second biggest cause of cancer deaths worldwide, resulting in 288,000 deaths annually. Could circumcision programmes reduce those deaths by a third, as a happy side-effect of HIV prevention programmes?
It does raise an interesting ethical question, though: when weighing costs and benefits of circumcision, how much weight should be given to something that does not affect the male directly, but rather a possible partner in the future? It's a difficult question, and I don't claim to have the answers.
Moving on, Anderson et al. have published what looks to be an interesting review entitled HIV Infection and Immune Defense of the Penis. Their subject matter, of course, is the mechanism by which circumcision protects against HIV. I haven't had the opportunity to read the full text, but from the abstract it appears that they reject the traditional view of the foreskin's mucosal layer as an HIV target, instead preferring a model in which the subpreputial cavity traps HIV and HIV-infected cells, bringing them into contact with the urethra. It's an interesting hypothesis, but I personally suspect that attempts to find a single explanation are doomed to failure; I believe that the protective effect seen is a result of multiple mechanisms acting together.
First, Wawer et al. published Effect of circumcision of HIV-negative men on transmission of human papillomavirus to HIV-negative women: a randomised trial in Rakai, Uganda. This is a fascinating study, not least because it is yet another study cleverly piggy-backed on one of the randomised controlled trials that effectively proved that circumcision reduces the risk of HIV. Results have been published previously showing that circumcision reduced the risk of (and increased clearance of) HPV infection in men; what's unusual about this study is that it directly measured the effect on infection in women (to be precise, the female partners of the men in the trial). And as previous observational studies indicated, the risk was reduced, from 38.7% to 27.8%.
The significance of this, of course, is that HPV is the virus responsible for cervical cancer in women (and about half of penile cancers in men). According to the World Health Organisation, cervical cancer is the second biggest cause of cancer deaths worldwide, resulting in 288,000 deaths annually. Could circumcision programmes reduce those deaths by a third, as a happy side-effect of HIV prevention programmes?
It does raise an interesting ethical question, though: when weighing costs and benefits of circumcision, how much weight should be given to something that does not affect the male directly, but rather a possible partner in the future? It's a difficult question, and I don't claim to have the answers.
Moving on, Anderson et al. have published what looks to be an interesting review entitled HIV Infection and Immune Defense of the Penis. Their subject matter, of course, is the mechanism by which circumcision protects against HIV. I haven't had the opportunity to read the full text, but from the abstract it appears that they reject the traditional view of the foreskin's mucosal layer as an HIV target, instead preferring a model in which the subpreputial cavity traps HIV and HIV-infected cells, bringing them into contact with the urethra. It's an interesting hypothesis, but I personally suspect that attempts to find a single explanation are doomed to failure; I believe that the protective effect seen is a result of multiple mechanisms acting together.
Wednesday, 20 October 2010
Attitudes re circumcision in Africa
This newly-published page shows the results of a set of Gallup surveys in a number of African countries.
They found that attitudes varied by country. The percentage who agreed with "male circumcision reduces the risk of being infected with HIV/AIDS" varied from 26% to 80%. The percentage of respondents agreeing with the statement "all men should be circumcised" varied from 39% to 85%.
Interestingly, both sets of responses were strongly related to education level: the more educated people were, their responses to the first question were more consistent with the scientific evidence, and their responses to the second were more "pro-circumcision".
The question is, is it that more educated people are more aware of circumcision, and more receptive to scientific information about it? Or is it that less educated people are less resistant to anti-circumcision propaganda, perhaps lacking the critical thinking skills that allow us to see it for what it is?
Some follow-up questions: how do we ensure that information about circumcision reaches the less educated members of society? Or, how can the less educated members of society be protected from anti-circumcision propaganda?
They found that attitudes varied by country. The percentage who agreed with "male circumcision reduces the risk of being infected with HIV/AIDS" varied from 26% to 80%. The percentage of respondents agreeing with the statement "all men should be circumcised" varied from 39% to 85%.
Interestingly, both sets of responses were strongly related to education level: the more educated people were, their responses to the first question were more consistent with the scientific evidence, and their responses to the second were more "pro-circumcision".
The question is, is it that more educated people are more aware of circumcision, and more receptive to scientific information about it? Or is it that less educated people are less resistant to anti-circumcision propaganda, perhaps lacking the critical thinking skills that allow us to see it for what it is?
Some follow-up questions: how do we ensure that information about circumcision reaches the less educated members of society? Or, how can the less educated members of society be protected from anti-circumcision propaganda?
Sunday, 23 May 2010
Reduced risk of sexual injuries in circumcised males
Yet another piggyback study using data from the HIV RCTs has been published. In this newly published study, using data gathered as part of the Kenyan trial, Mehta et al. report reduced risk of "penile coital injuries".
The authors report:
So, these injuries — while minor — are fairly common and disproportionately affect uncircumcised males.
The authors suggest that this may affect the risk of HIV acquisition. This seems perfectly plausible, though it would be a mistake, I believe, to say that it is "the" mechanism by which circumcision protects against HIV. What's becoming clear, I think, is that circumcision protects against HIV through multiple mechansisms acting simultaneously.
I wonder, though, whether these findings might partly explain the fact that several studies have found that dyspareunia (painful intercourse) is more common among uncircumcised males?
The authors report:
At baseline 1,775 (64.4%) men reported any coital injury including 1,313 (47.6%) soreness, 1,328 (48.2%) scratches, abrasions or cuts and 461 (16.7%) bleeding. On multivariable analysis coital injury risk was lower for circumcised than for uncircumcised men with soreness (OR 0.71, 95% CI 0.64-0.80), scratches/abrasions/cuts (OR 0.52, 95% CI 0.46-0.59), bleeding (OR 0.62, 95% CI 0.51-0.75) and any coital injury (OR 0.61, 95% CI 0.54-0.68).
So, these injuries — while minor — are fairly common and disproportionately affect uncircumcised males.
The authors suggest that this may affect the risk of HIV acquisition. This seems perfectly plausible, though it would be a mistake, I believe, to say that it is "the" mechanism by which circumcision protects against HIV. What's becoming clear, I think, is that circumcision protects against HIV through multiple mechansisms acting simultaneously.
I wonder, though, whether these findings might partly explain the fact that several studies have found that dyspareunia (painful intercourse) is more common among uncircumcised males?
Saturday, 8 May 2010
Fatally flawed: Bollinger's circumcision death calculations
Dan Bollinger (of the International Coalition for Genital Integrity) has published "LOST BOYS: AN ESTIMATE OF U.S. CIRCUMCISION-RELATED INFANT DEATHS". In it, he claims that circumcision causes 117 deaths per year in the United States. It's a lengthy paper, and is frankly rather tedious to wade through, but I thought it might be interesting to see how he derived his estimate:
(Here Bollinger references a figure he has provided previously: "Hospital discharge records reveal that, during the 1991–2000 decade, on average 35.9 boys died from all causes each year during their stay (average 2.4 days) in the hospital in which both their birth and circumcision occurred (Thompson Reuters, 2004).")
This is indeed a relatively safe assumption, though it is not one that actually gets us any closer to an answer.
This is extraordinary! Bollinger is, in effect, assuming that the difference between male and female death rates is due entirely to circumcision. But it is a well-established fact that male babies are more susceptible to deaths than females, and there is no evidence that this is due to circumcision. Indeed, if circumcision alone were responsible for the difference, then we might expect countries with low circumcision rates to have the same infant mortality rates among males and females. But in fact, that's not the case, as the following table shows:
Table: Infant mortality (IM) rates for selected countries. Derived from female rate table and male rate table.
Clearly, infant mortality rates are consistently higher among males regardless of circumcision rates. So Bollinger's approach is clearly flawed. When he is trying to estimate the risk due to circumcision he is actually estimating the risk due to being male!
But it gets even worse (this would be laughable if the subject weren't so serious). Even if we assume that Bollinger's method is sane and appropriate (in spite of evidence to the contrary), he manages to miscalculate those attributable to being male. If the rate is 40.4% higher among males then the observed rate (35.9) will be the rate in females plus 0.404 times that rate again (or 1.404 times the rate in females). So, to find the rate in females:
1.404f = 35.9
f = 35.9 / 1.404 = 25.57
And so the rate attributable to being male will be 40.4% of that, which is 10.33.
But, as noted, this is the rate attributable to being male, not to circumcision.
Bollinger expresses this with less than optimal clarity, but what he seems to be saying is that the ratio between deaths in the hospital stay (which Bollinger identifies as typically 2.4 days) and those after the hospital stay (but presumably within the first 28 days of life) is 7.72.
Frankly, that shouldn't be surprising. There are 10.7 times as many days in the latter period than there are in the former, so one would ordinarily expect more deaths simply due to there being more time in which people can die.
This multiplication is irrational. It stands to reason that there would be more deaths in the first 28 days than the first 2.4 days, simply because there is more time in which infants can die. If we look at the first 100 years of life, then the ratio will be even greater (in fact, the mortality rate over that period will be almost 100%), but would it make any sense to apply that ratio? Of course not — people die of other things than circumcision, and it wouldn't make any sense.
It doesn't make sense to apply this multiplication, either. Yes, a certain number of circumcision-related deaths will likely occur some time after the event, but it doesn't make any sense to assume, in effect, that any deaths in the period must be due to circumcision.
It is perhaps a little disingenuous to refer to these as "estimates". These are observations showing 1 death in 566,000 circumcisions (Speert), no deaths in 100,000 boys (Wiswell). Similarly, King reported no deaths in 500,000 circumcisions. So if we use 1 in 500,000 as a reasonable estimate, we would expect 2.6 deaths in 1.3 million circumcisions. Bollinger's errors have led him to a figure some 45 times greater than that which can be extrapolated from actual statistics!
Yes, I suppose the nice thing about imaginary numbers is that there is an inexhaustible supply of them.
Though the data previously cited are insufficient to establish a definitive death rate on their own, there is enough available information to calculate an estimate. Not all of the reported 35.9 deaths out of 1,243,392 circumcisions can be attributed to related causes.
(Here Bollinger references a figure he has provided previously: "Hospital discharge records reveal that, during the 1991–2000 decade, on average 35.9 boys died from all causes each year during their stay (average 2.4 days) in the hospital in which both their birth and circumcision occurred (Thompson Reuters, 2004).")
What portion, then, is circumcision-related and how may we extrapolate to the number of deaths after hospital release? What we can safely assume is that it is unlikely that any of these infants would have been subjected to the unnecessary trauma of circumcision if they had been in critical condition, or that they would have been circumcised after their death.
This is indeed a relatively safe assumption, though it is not one that actually gets us any closer to an answer.
Gender-ratio data can help extrapolate a figure. Males have a 40.4% higher death rate than females from causes that are associated with male circumcision complications, such as infection and hemorrhage,4 during the period of one hour after birth to hospital release (day 2.4), the time frame in which circumcisions are typically performed (CDC, 2004). Assuming that the 59.6% portion is unrelated to gender, we can estimate that 40.4% of the 35.9 deaths were circumcision-related. This calculates to 14.5 deaths prior to hospital release.
This is extraordinary! Bollinger is, in effect, assuming that the difference between male and female death rates is due entirely to circumcision. But it is a well-established fact that male babies are more susceptible to deaths than females, and there is no evidence that this is due to circumcision. Indeed, if circumcision alone were responsible for the difference, then we might expect countries with low circumcision rates to have the same infant mortality rates among males and females. But in fact, that's not the case, as the following table shows:
| Country | Est. neonatal circ. rate | IM (male) | IM (female) | IM m:f ratio |
|---|---|---|---|---|
| Israel | > 90% | 4.39 | 4.05 | 1.08 |
| Nigeria | 80-90% | 100.38 | 87.97 | 1.14 |
| United States | 50-80% | 6.90 | 5.51 | 1.25 |
| Australia | < 20% | 5.08 | 4.40 | 1.15 |
| United Kingdom | < 5% | 5.40 | 4.28 | 1.26 |
| France | < 5% | 3.66 | 2.99 | 1.22 |
| Finland | < 1% | 3.78 | 3.15 | 1.2 |
Table: Infant mortality (IM) rates for selected countries. Derived from female rate table and male rate table.
Clearly, infant mortality rates are consistently higher among males regardless of circumcision rates. So Bollinger's approach is clearly flawed. When he is trying to estimate the risk due to circumcision he is actually estimating the risk due to being male!
But it gets even worse (this would be laughable if the subject weren't so serious). Even if we assume that Bollinger's method is sane and appropriate (in spite of evidence to the contrary), he manages to miscalculate those attributable to being male. If the rate is 40.4% higher among males then the observed rate (35.9) will be the rate in females plus 0.404 times that rate again (or 1.404 times the rate in females). So, to find the rate in females:
1.404f = 35.9
f = 35.9 / 1.404 = 25.57
And so the rate attributable to being male will be 40.4% of that, which is 10.33.
But, as noted, this is the rate attributable to being male, not to circumcision.
But as is often the case with hemorrhage and infection, some circumcision-related deaths occur days, even weeks, after hospital release. The CDC’s online searchable database, Mortality: Underlying cause of death, 2004 (CDC), lists causes by various age ranges and reveals that the percentage of deaths after release, compared with deaths before, is 772% greater. This ratio is comparable to Patel’s (1966) 700% postrelease infection rate.
Bollinger expresses this with less than optimal clarity, but what he seems to be saying is that the ratio between deaths in the hospital stay (which Bollinger identifies as typically 2.4 days) and those after the hospital stay (but presumably within the first 28 days of life) is 7.72.
Frankly, that shouldn't be surprising. There are 10.7 times as many days in the latter period than there are in the former, so one would ordinarily expect more deaths simply due to there being more time in which people can die.
Multiplying the 772% adjustment factor for age-at-time-of-death by the 14.5 hospital-stay deaths calculated above, the result is approximately 112 circumcision-related deaths annually for the 1991–2000 decade, a 9.01/100,000 death-incidence ratio.
This multiplication is irrational. It stands to reason that there would be more deaths in the first 28 days than the first 2.4 days, simply because there is more time in which infants can die. If we look at the first 100 years of life, then the ratio will be even greater (in fact, the mortality rate over that period will be almost 100%), but would it make any sense to apply that ratio? Of course not — people die of other things than circumcision, and it wouldn't make any sense.
It doesn't make sense to apply this multiplication, either. Yes, a certain number of circumcision-related deaths will likely occur some time after the event, but it doesn't make any sense to assume, in effect, that any deaths in the period must be due to circumcision.
Applying this ratio to the 1,299,000 circumcisions performed in 2007, the most recent year for which data are available (HCUP, 2007), the number of deaths is about 117. This is equivalent to one death for every 11,105 cases, which is not in substantial conflict with Patel’s observation of zero deaths in 6,753 procedures. It is more than some
other estimates (Speert, 1953; Wiswell, 1989),
It is perhaps a little disingenuous to refer to these as "estimates". These are observations showing 1 death in 566,000 circumcisions (Speert), no deaths in 100,000 boys (Wiswell). Similarly, King reported no deaths in 500,000 circumcisions. So if we use 1 in 500,000 as a reasonable estimate, we would expect 2.6 deaths in 1.3 million circumcisions. Bollinger's errors have led him to a figure some 45 times greater than that which can be extrapolated from actual statistics!
but less than the overstated 230 figure derived from Gairdner (1949). Breaking this statistic down further, about 40% of these deaths (47) would have been from hemorrhage, and the remainder (70) from sepsis, using a hemorrhage-to-sepsis ratio for infant mortality (NCHS, 2004).
Yes, I suppose the nice thing about imaginary numbers is that there is an inexhaustible supply of them.
Tuesday, 20 April 2010
20 reasons revisited
SagaciousMama has posted an article entitled 20 Reasons I Did Not Circumcise My Son.
Now I'm supportive of parents who choose not to circumcise, as well as those who do, but this article is alarmingly misinformed. Here's my analysis.
Always? Even when local anaesthetic is used? If that were so, men circumcised as adults would report unbearable pain. But in fact, men circumcised under local anaesthetic generally report only mild pain, if any. (Eg., Long et al. report "No patient experienced pain during circumcision.")
This is a common anti-circ myth. In fact, the fingernail is fused to the nail bed; in contrast the foreskin's attachment to the glans is primed to detach anyway, and can easily be separated. (This is quite obvious from the many circumcision technique videos on the Internet, which show that the foreskin can be detached through moving a probe around, without excessive force.)
Here SagaciousMama cites only a number of weak sources. These sources speculate that neonatal circumcision causes numerous psychological problems, but they fall short of the most important quality of scientific work: testing one's hypothesis. In no cases do they provide any evidence showing that their theory is correct.
Until they do their theories don't really seem worthy of a response.
No, it isn't. "Mutilation" is defined as:
1. To deprive of a limb or an essential part; cripple.
The foreskin isn't a limb, and it is clearly not essential, since if it were we would not be able to survive without it.
2. To disfigure by damaging irreparably: mutilate a statue.
Circumcision neither damages nor disfigures. If it damaged the penis, then there would be clear evidence that the penis functioned better with a foreskin than without, but — if anything — the opposite seems to be true. "Disfigurement" is a little more subjective, but the fact that circumcision is widely perceived as a cosmetic improvement is incompatible with the notion that it is a disfigurement.
3. To make imperfect by excising or altering parts.
Again, this is somewhat subjective. That circumcision excises the foreskin is clear, but does this make the penis imperfect? Or does it make it more perfect?
Since SagaciousMama appears to indicate that her statement is a kind of timeless truth, frankly I think she needs something stronger than highly subjective assessments.
This is a repeat. See no. 1.
It would be impossible to alter a girl in this way: girls don't have penes. But, as a hypothetical, suppose that there was a form of minor surgery that could be performed on girls, that had multiple benefits, minimal risks, and no long-term harms. Would it be rational to oppose it?
Here SagaciousMama quotes the ever nutty circumstitions.com:
Oh dear. It's troubling that anyone can find this line of argument convincing. The basic idea is this: construct a list of positive claims that have ever been made about a subject, regardless of merit or basis in evidence. Now present them side by side. For example, you can show that hand-washing used to be a religious ritual in ancient times, and more recently, as germs became known, it was promoted for that reason. It's true, but what does it prove? That we should abandon handwashing? Of course not — such a conclusion is ludicrous.
With a little interpretation, what SagaciousMama is claiming here is that there are no advantages to circumcision. That's wildly incorrect: there are multiple health benefits to circumcision, including prevention of phimosis, balanoposthitis, urinary tract infection, HIV, HPV and (some) other STDs, penile cancer, etc. Some of these benefits are very minor, some less so, but to say that they don't exist is simply absurd.
Actually, you do, but you don't have to exercise that right if you don't want to.
What planet is SagaciousMama living on? There's a reasonable overview of study results at Wikipedia. Far from regret being "almost inevitable", high rates of satisfaction are commonplace.
According to what evidence? Almost none. Studies of penile sensitivity have almost invariably shown no statistically significant differences. See, eg., Masters & Johnson, Bleustein 2003, Bleustein 2005, Payne 2007. None of these studies were performed on recently circumcised men, and none were able to find evidence of this desensitisation.
True, and what do they (we, strictly speaking) describe? "After the procedure 82% of patients referred an upgrade on the quality of their sexual intercourse, ...", "Compared to before they were circumcised, 64.0% of circumcised men reported their penis was "much more sensitive," ...", "Penile sensation improved after circumcision in 38% (p = 0.01) but got worse in 18%, with the remainder having no change."
There's really no reliable evidence that this is the case. SagaciousMama cites a dubious website on the subject, which is full of speculative nonsense but very little evidence.
True, though it's not exactly an argument against circumcision.
This is technically true, but neither is adult circumcision the same as infant circumcision (it almost invariably causes heavier scarring, for example), so whatever choice you make will have lasting consequences.
Yes, there are risks, albeit small. These should be considered alongside the risks associated with non-circumcision (such as death due to complications of UTI, for example).
This is too silly to deserve a response.
No. It doesn't.
I'm going to skip this one because, as far as I can tell, SagaciousMama is basically just saying that it is incompatible with her personal parenting philosophy. That seems a good reason not to circumcise.
Not really, no.
Yikes. This is frighteningly irrational: deciding against something because of the reasons why people used to do it. It's like being opposed to dancing because some tribes, somewhere in the world, perform rain dances in the belief that it will induce precipitation. So what? Given the number of human societies and their longevity, it seems inevitable that sometimes people do good things for stupid reasons.
This isn't a very rational argument. A considerable fraction of the world's population lack clean water, but this doesn't strike me as a compelling argument for having my water supply disconnected. The correct figure is probably closer to 60%, by the way.
This is simply nonsense.
Now I'm supportive of parents who choose not to circumcise, as well as those who do, but this article is alarmingly misinformed. Here's my analysis.
1) The Pain is Excruciating
Always? Even when local anaesthetic is used? If that were so, men circumcised as adults would report unbearable pain. But in fact, men circumcised under local anaesthetic generally report only mild pain, if any. (Eg., Long et al. report "No patient experienced pain during circumcision.")
The foreskin is attached like a fingernail (see #4).
This is a common anti-circ myth. In fact, the fingernail is fused to the nail bed; in contrast the foreskin's attachment to the glans is primed to detach anyway, and can easily be separated. (This is quite obvious from the many circumcision technique videos on the Internet, which show that the foreskin can be detached through moving a probe around, without excessive force.)
2) The procedure and pain has long lasting consequences.
Here SagaciousMama cites only a number of weak sources. These sources speculate that neonatal circumcision causes numerous psychological problems, but they fall short of the most important quality of scientific work: testing one's hypothesis. In no cases do they provide any evidence showing that their theory is correct.
Until they do their theories don't really seem worthy of a response.
3) It is genital mutilation.
No, it isn't. "Mutilation" is defined as:
1. To deprive of a limb or an essential part; cripple.
The foreskin isn't a limb, and it is clearly not essential, since if it were we would not be able to survive without it.
2. To disfigure by damaging irreparably: mutilate a statue.
Circumcision neither damages nor disfigures. If it damaged the penis, then there would be clear evidence that the penis functioned better with a foreskin than without, but — if anything — the opposite seems to be true. "Disfigurement" is a little more subjective, but the fact that circumcision is widely perceived as a cosmetic improvement is incompatible with the notion that it is a disfigurement.
3. To make imperfect by excising or altering parts.
Again, this is somewhat subjective. That circumcision excises the foreskin is clear, but does this make the penis imperfect? Or does it make it more perfect?
Since SagaciousMama appears to indicate that her statement is a kind of timeless truth, frankly I think she needs something stronger than highly subjective assessments.
4) In babies, the foreskin is attached like a fingernail.
This is a repeat. See no. 1.
5) I wouldn’t alter a girl in this way, and boys count, too.
It would be impossible to alter a girl in this way: girls don't have penes. But, as a hypothetical, suppose that there was a form of minor surgery that could be performed on girls, that had multiple benefits, minimal risks, and no long-term harms. Would it be rational to oppose it?
Here SagaciousMama quotes the ever nutty circumstitions.com:
For over a hundred years, circumcision has been a solution looking for a problem, and the problem has typically been the most frightening disease of the day - ... “masturbation insanity” in the 19th century, ... then tuberculosis, ... Sexually Transmitted Diseases (then called Venereal Disease or VD) after World War I, ... penile cancer in the 1930s, and ... * cervical cancer in the 1950s, when cancers were terrifyingly untreatable, ... urinary tract infections from 1982 onward, ... * and now HIV.
Oh dear. It's troubling that anyone can find this line of argument convincing. The basic idea is this: construct a list of positive claims that have ever been made about a subject, regardless of merit or basis in evidence. Now present them side by side. For example, you can show that hand-washing used to be a religious ritual in ancient times, and more recently, as germs became known, it was promoted for that reason. It's true, but what does it prove? That we should abandon handwashing? Of course not — such a conclusion is ludicrous.
6) It is pointless and absolutely unnecessary. ... There are no advantages to genital mutilation for either a boy or a girl however there are many disadvantages and risks.
With a little interpretation, what SagaciousMama is claiming here is that there are no advantages to circumcision. That's wildly incorrect: there are multiple health benefits to circumcision, including prevention of phimosis, balanoposthitis, urinary tract infection, HIV, HPV and (some) other STDs, penile cancer, etc. Some of these benefits are very minor, some less so, but to say that they don't exist is simply absurd.
7) I don’t have the right.
Actually, you do, but you don't have to exercise that right if you don't want to.
8.) Decreases sensitivity. ... This is the most studied and obvious aspect of this topic. Regardless of the volumes of studies on the tissue, the science, etc, the best evidence of this comes from studies of intact men who get circumcised as adults. Regret is almost inevitable. They do this for newly adopted religious reasons, misguided ideas or information on benefits and other reasons.
What planet is SagaciousMama living on? There's a reasonable overview of study results at Wikipedia. Far from regret being "almost inevitable", high rates of satisfaction are commonplace.
The foreskin is full of nerve endings and is the cause of natural lubrication. It is also a protective cover. Removing that cover exposes the glans of the penis to constant stimulation and rubbing against clothing. This idea makes an intact male shudder. Where some people think the exposed glans heightens sensitivity and sexual pleasure, the reverse is actually true. The penis desensitises to cope. The newly cut man will experience heightened sensitivity, however it is usually uncomfortable more than enjoyable and it does not last.
According to what evidence? Almost none. Studies of penile sensitivity have almost invariably shown no statistically significant differences. See, eg., Masters & Johnson, Bleustein 2003, Bleustein 2005, Payne 2007. None of these studies were performed on recently circumcised men, and none were able to find evidence of this desensitisation.
If you ask a circumcised man about sexuality and sensitivity he will usually tell you everything is fine, great, just dandy. However, he doesn’t know it any other way. You can’t miss something you’ve never had. Only those who have been circumcised as adults have that perspective.
True, and what do they (we, strictly speaking) describe? "After the procedure 82% of patients referred an upgrade on the quality of their sexual intercourse, ...", "Compared to before they were circumcised, 64.0% of circumcised men reported their penis was "much more sensitive," ...", "Penile sensation improved after circumcision in 38% (p = 0.01) but got worse in 18%, with the remainder having no change."
9) Causes problems for female partners.
There's really no reliable evidence that this is the case. SagaciousMama cites a dubious website on the subject, which is full of speculative nonsense but very little evidence.
10) The option will always be there when he grows up.
True, though it's not exactly an argument against circumcision.
11) It is irreversible. ... Restoration is not the same.
This is technically true, but neither is adult circumcision the same as infant circumcision (it almost invariably causes heavier scarring, for example), so whatever choice you make will have lasting consequences.
12) Risk of Physical Damage and Death.
Yes, there are risks, albeit small. These should be considered alongside the risks associated with non-circumcision (such as death due to complications of UTI, for example).
13) Babies Tell You They Don’t Want To Be Circumcised.
This is too silly to deserve a response.
14) Interferes With Breastfeeding.
No. It doesn't.
15) It Goes Against Natural and Attachment Parenting
I'm going to skip this one because, as far as I can tell, SagaciousMama is basically just saying that it is incompatible with her personal parenting philosophy. That seems a good reason not to circumcise.
16) It is Medieval, Shocking Barbaric and Weird. ... and ... 17) Spread eagled restraint is like torture to a baby.
Not really, no.
18.) The historical reasons for it are morality based
Yikes. This is frighteningly irrational: deciding against something because of the reasons why people used to do it. It's like being opposed to dancing because some tribes, somewhere in the world, perform rain dances in the belief that it will induce precipitation. So what? Given the number of human societies and their longevity, it seems inevitable that sometimes people do good things for stupid reasons.
19) 80% of the World’s Males are Intact.
This isn't a very rational argument. A considerable fraction of the world's population lack clean water, but this doesn't strike me as a compelling argument for having my water supply disconnected. The correct figure is probably closer to 60%, by the way.
20) The Foreskin is a Necessary and Amazing Anatomical Structure.
This is simply nonsense.
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