Circumcision

Infant circumcision (removal of the foreskin) is highly controversial, and yet in North America it is perhaps the single most common surgical procedure. Proponents claim that it promotes good health and hygiene, and some see it as a perfectly harmless religious obligation. Detractors claim that the foreskin performs various functions, and that no medical, theological, or aesthetic justifications warrant its painful and permanent removal from helpless babies.

Following, I have critiqued the major pro-circumcision arguments as dispassionately as I can, in an attempt to determine who the facts vindicate: those who are in favor of circumcision as a routine procedure, or those who are stiffly opposed.

Argument #1: It is a weapon in the battle against STDs

Modern advocates claim that circumcised males are much less likely to contract various sexually transmitted diseases (STDs), including but not limited to HIV and HPV; and upon this rests the bulk of their case. In fact, the blog Science-Based Medicine features a post entitled The Case for Neonatal Circumcision which rests entirely on this claim; and the author, Amy Tuteur, begins by voicing the frustration that many in the pro-circumcision camp must feel:

"Imagine if we could save lives from a dread and often fatal disease simply by performing a minor surgical procedure. People would hail this simple victory and rush to adopt it... Not exactly. The disease is HIV and the simple surgical procedure is circumcision and anti-circ activists oppose it under almost any circumstances."

In fact Tuteur has good evidence to back her up: two large studies published in 2007 (one conducted in Kenya and the other in Uganda) both concluded that circumcision rendered heterosexual men significantly less likely to contract HIV; and a 2009 study (also conducted in Uganda), confirmed this, and in addition found that circumcision decreased the transmission of HPV and herpes (HSV-2), although the mechanism responsible remains speculative.

Collectively, these diseases have killed many millions of people, and I have to agree that those who would summarily dismiss these results are utterly indefensible. And yet I am sure Tuteur would agree we cannot wage war on these diseases by any means necessary; that human rights must not be trampled in a rush to victory. Thus the question becomes: is circumcision an appropriate means of tackling these diseases?

Bachmann attacking Perry for
mandating an HPV vaccine

For the sake of context, consider compulsory vaccination. For although vaccines have proven themselves a highly effective weapon in the struggle against many infectious diseases, even their most voracious proponents tend to get queasy when asked if vaccination should be mandated by the government. This is because freedom of choice is widely held to be a basic human right.

Of course, babies cannot choose for themselves whether or not to get circumcised, and thus parents are entitled to make this and other decisions on their behalf. This is undeniably reasonable.

But are parents entitled to have their babies circumcised on the grounds that it will reduce their chances of contracting and spreading STDs? 

To my mind, the answer to this question is: no. After all, for the vast majority of their sex lives, males are mature adults, complete with the capacity to make decisions for themselves. Considering this, it seems bizarre to me that in making The Case for Neonatal Circumcision, Tuteur never thought to argue for the circumcision of babies.

To be fair, others have bothered to bridge this gap, and Tuteur could have mentioned that circumcision is a greater inconvenience for adults (which is certainly true); that circumcision causes adults more pain (which is debatable and ultimately unverifiable); or that adult circumcision is more likely to result in health complications (which appears to be true). But she also failed to point out that many men might well choose not to sacrifice their foreskins given the opportunity to choose for themselves, and that this makes the case for taking it from them as infants ethically questionable.

That said, it should be noted that these studies were conducted in countries wherein infection rates are much higher than they are in North America (at least for HIV), and resources relatively limited. Thus their conclusions reflect an urgent need for inexpensive interventions, and do not necessarily make a good case for routine circumcision in the Occident. There is every reason to believe, for example, that simply using a condom would overwhelm this effect; and there is little evidence that circumcision effects HIV transmission among homosexual men, who represent the primary mode of transmission in the West.

(Side note: Amy Tuteur no longer writes for the usually excellent Science-Based Medicine due to "unresolvable differences" with the editors.)

Argument #2: Circumcision protects against UTIs and penile cancer

Circumcision proponents also claim that it protects against noncommunicable afflictions such as urinary tract infections (UTIs) and penile cancer; and in fact here too it appears that the preponderance of published studies is on their side. UTIs, however, are fairly uncommon in males and one study estimated that, statistically, up to

"195 circumcisions would be needed to prevent one hospital admission for UTI in the first year of life."

(although some estimates are lower; and some UTIs are asymptomatic) Furthermore, most UTIs are treatable by other means and do little harm beyond pain and discomfort (circumcisions also cause pain); and although some UTIs can lead to more serious complications, this is so rare that a 2004 review of the circumcision/UTI literature concluded that a

"net clinical benefit is likely only on boys at high risk of UTI"

Penile cancers are also rare - so rare in fact, that it is difficult to asses its risk factors. It seems possible, however, that they are more common among uncircumcised men. Why this might be remains unclear (shameless speculation: could it be in part because fewer cells simply reduces the chances that one of them will spawn a tumor, and could this also help explain why tall people appear to be at a higher risk of cancer?), but since hygiene appears to play a role, prophylactic measures far less extreme than circumcision readily suggest themselves . In any case, since this disease is clearly associated with age, (two-thirds of American penile cancers occur in seniors), I think it can be safely dismissed as a good reason to circumcise infants.

Argument #3: The foreskin is useless; thus even small benefits warrant its removal

Of course, we cannot simply lop off every body part that is at risk of cancer and infection, and thus in making their case for circumcision advocates sometimes liken the foreskin to the appendix - that bothersome intestinal protrusion which does little beyond rendering the human body more vulnerable to suffering. Of course, their opponents disagree, often by claiming that natural selection would not have made such a foolish error.

As someone who is keenly interested in biological evolution, I find this aspect of the debate quite exciting. For the claim, stated by anti-circumcision activist Paul M. Fleiss, that

"the human body [is] a model of refinement, elegance, and efficiency, with every part having a function and purpose",

is highly unlikely (what function, I wonder, would Dr. Fleiss assign to the male nipple?); and whether or not the foreskin has utility - not to mention whether it has relevance in the context of the modern world - is an excellent question, to which a simple answer is not immediately apparent.

Koala foreskins host bacteria that
appear to assist their reproduction

Perhaps the most commonly alleged function of the foreskin contributes to sexual pleasure (for him or her or both); and this is supported by the observations that the foreskin houses a high concentration of nerves, and that its loss reduces penile girth. But pleasure is subjective, and thus the degree to which it is impacted by circumcision cannot be verified with absolute certainty. Moreover, reports from men circumcised as adults (and from their partners) appear to be mixed; and it seems possible that there exists some key difference between neonatal and adult circumcision with respect to sexual pleasure.

Opponents of circumcision also point out that foreskins are nearly universal among mammals, and that this would not be so if they did not posses survival value. To this it must be said that nonhuman foreskins differ from our own in potentially key respects; and their value to humans could have been rendered superfluous by the dawning of modern civilization: by clothing, regular bathing, or medical science. However, the observation that we have retained them despite evolving in uncivilized circumstances, does suggest that their portrayal as a significant detriment to health and hygiene is probably unfounded.

More importantly, this conclusion is supported by the observation that few if any North American health organizations advocate routine circumcision on medical grounds, including The College of Physicians and Surgeons of British Columbia, which has unequivocally stated that

"routine infant male circumcision... is not recommended."

Argument #4: It's a religious obligation/cultural tradition

God, it is widely believed, gave our sons foreskins so that we might slice them off (in fact circumcision is very prevalent in the Muslim world as well as among Jews, although many of the former apparently consider it to be proper, as opposed to obligatory). This poses a dilemma for anti-circumcision movements, for it is difficult to effectively fight against if one is content to allow its proponents to retreat from medical to theological grounds; and yet it can be difficult to fight on theological grounds without appearing to attack that theology as a whole.

Foreskin Man battles
Monster Mohel

For example, take Foreskin Man. The anti-circumcision superhero comic was widely condemned as antisemitic, the hero's blonde hair was described as "suspiciously Aryan", and it was even been compared to "1930s Nazi propaganda", when it depicted a demonized Jewish mohel as a villain. In contrast, little indignation was aroused when Foreskin Man did battle with an equally demonized circumcision-performing doctor.

Theological grounds are also more advantageous to the defense of circumcision in that while it must be shown to have health benefits to be endorsed as a medical procedure, those who merely proclaim it a religious right can content themselves with asking "what's the harm?" - and the existence of millions of happy, healthy, and functioning circumcised men might seem to imply that there is none. Indeed, during a debate with atheist Christopher Hitchens, rabbi Harold Kushner felt so confident of this that he joked

"Statistically, the only long-term effect that [circumcision] seems to have on people is it increases their chances of winning a Nobel prize." (click here to see Hitchens' righteous response)

The notion of harmlessness is also how modern Western populations square their tolerance of male circumcision with the ubiquitous laws that expressly prohibit its female counterpart - laws which permit no religious or cultural exceptions.

And yet there clearly are harms associated with infant circumcision - or, at the very least, there are risks - which to my mind clearly supersede any conceivable non-medical argument:

• like all surgeries, it can result in complications ranging from minor infections and bleeding to permanent scarring or death;
• it is painful, and use of anesthesia accompanies still further risk of complication;
• it risks negatively effecting a child's future sex life and that of their future partner;
• it irreversibly alters one's appearance (perhaps barring restoration therapy); and
• it risks violating the wishes of children, possibly causing them to resent it as they age.

This last point is perhaps especially true in the case of religious circumcision, since people are even less likely to be devout Muslims or Jews as infants than they are to be sexually mature and suffering from penile cancer. And if they do not come to share their parents spiritual views, the knowledge that they were circumcised as a way of signifying to which religion they belonged might be even less palatable to children than the knowledge that it was done for misguided medical reasons.

 * * *

It should further be noted that circumcision was commonplace in North America well before evidence of any medical benefit was available - in fact before HIV and HPV were even discovered; and that long-abandoned arguments in favor of it (such as the discouragement of masturbation) still indirectly impact the decisions of parents today. For example: they persuaded many states and provinces to subsidize routine circumcision under their public health plans, as many states still do; and they caused it to be widely seen as "normal" by pushing circumcision rates well above 50%. A great many parents choose circumcision merely so that the son "looks like the father", regardless of whether it made sense that the father was circumcised in the first place (I can't help but wonder whether some maternal instinct to reassure partners of their biological fatherhood is at play here); and perhaps this suggests that, along with the wishes of the infant in question, those of his future progeny should also be factored into the equation.

We certainly have a duty to do our utmost to rid ourselves of infectious diseases. And we have a duty to make children aware of their heritage. But we also have a duty to respect, insofar as is possible, the individual's right to freedom of choice; and to think critically, that we might disrupt the propagation of nonsensical memes from one generation to the next. Since the medical consensus is currently against routine circumcision of North American children, and since I cannot bring myself to accept spiritual or cosmetic reasons as sufficient to place an unwitting child under the knife, I think it is clear which responsibilities take precedence in this case.

This post is dedicated to my dear mother.