Brian D. Earp believes circumcision is worth talking about. And he would like Mr. Stern and the editors of Slate magazine to know why.
I recently read your article, βHow Circumcision Broke the Internetβ forΒ SlateΒ magazine [republished as "'Intactivists' Against Circumcision" in Canada'sΒ National Post]. I understand your concern about overheated rhetoric in public debates as well as the misuse of science to support untenable positions. As a scientist and ethicist who studies circumcision professionally, I will admit that I have seen this happen on both sides of this particular controversy. I think, however, that in your hurry to admonish βthe intactivistsβ for pushing their anti-circumcision arguments too far, you may have fallen prey to some of that very same rhetorical excess (as well as misuse of science) in your own piece.
First, when you said that circumcision used to be βpracticed by most familiesβ Iβm glad that you added the qualifier, βin America at least.β This is an important point. Circumcision is extremely uncommon in most parts of the world, and aboutΒ 70-80%Β of men globally are left intact. OverΒ 70% of those who are circumcisedΒ come from Muslim communities where it is done as a rite of passage; it is also a rite of passage in countries like South Africa, where at leastΒ 39Β young menΒ recently diedΒ from complications related to circumcision, such asΒ excessive bleedingΒ from their penises. Europeans, by contrast, very rarely circumcise outside of religious communities, and a majority of European doctors are quite firm that any βhealth benefitsβ conferred by circumcisionβeven when the procedure is properly performedβare dubious at best. In fact,Β 38 of Europeβs most pre-eminentΒ medical authorities recently expounded on this point in the flagship journalΒ Pediatrics:
Only one of the arguments put forward by the American Academy of Pediatrics [concerning potential health benefits for circumcision] has some theoretical relevance in relation to infant male circumcision; namely, the possible protection against urinary tract infections in infant boys, which can easily be treated with antibiotics without tissue loss. The other claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts, and penile cancer, are questionable, weak, and likely to have little public health relevance in a Western context, and they do not represent compelling reasons for surgery before boys are old enough to decide for themselves.
Also, I noticed that you cite a βsystematic reviewβ by Brian Morris (and a co-author) in support of one of your claims about penile sensitivity. Your readers may not be aware that Professor Morris runs a pro-circumcisionΒ advocacy website, has founded a highly activeΒ circumcision lobby groupΒ (some of whoseΒ board membersΒ derive a substantial income from performing circumcisions), and has recently beenΒ profiledΒ in theΒ International Journal of EpidemiologyΒ as being engaged in systematicallyΒ distortingΒ the academic literature on circumcision:
[As] in critical letters to the editor following other recent studies that failed to support their agenda, Morris et al. air a series of harsh criticisms against our study. As seen, however, the points raised are not well founded. It seems that the main purpose, as with prior letters, is to be able in future writings to refer to our study as an βoutlier studyβ or one that has been βdebunkedβ, βrejected by credible researchersβ or βshown wrong in subsequent proper statistical analysis.β β¦ As these critics repeatedly refer to Morrisβ pro-circumcision manifesto as their source of knowledge, their objectivity must be questioned.
Perhaps it is not much of a surprise, then, that Professor Morrisβ βsystematic reviewsβ tend to yield results that come out rather favorable toward circumcision.Β In other words, it isnβt quite enough to simply dredge up a reference in support of your point of view β anyone with a computer and access to the internet can do that. Instead, researchers who study circumcision more seriously have to consider that even the most basic science on the subject is as complex as it is contentious. For example,Β this recent paperΒ criticizes the methodology of the βsexual satisfactionβ findings from the African studies you mentioned:
Rather than blindly accepting such findings as any more trustworthy than other findings in the literature, it should be recalled that a strong study design, such as a randomized controlled trial, does not offset the need for high-quality questionnaires. Having obtained the questionnaires from the authors (RH Gray and RC Bailey, personal communication), I am not surprised that these studies provided little evidence of a link between circumcision and various sexual difficulties. Several questions were too vague to capture possible differences between circumcised and not-yet circumcised participants (e.g. lack of a clear distinction between intercourse and masturbation-related sexual problems and no distinction between premature ejaculation and trouble or inability to reach orgasm). Thus, non-differential misclassification of sexual outcomes in these African trials probably favoured the null hypothesis of no difference, whether an association was truly present or not.
Speaking of those African trials, you write that βcircumcisionΒ lowers the riskΒ of HIV acquisition in heterosexual men by aboutΒ 60Β toΒ 70 percent.β But you left out a few important qualifiers. First, those studies have beenΒ heavily criticizedΒ βΒ notwithstanding that they have also beenΒ defended,Β by none other than our good friend Brian Morris (see above) along with his usual team of collaborators including the software engineer and βinternationally recognized circumcision activistβΒ Jake Waskett. Among other issues, not one of the studies wasΒ placebo-controlledΒ (which could have been accomplished by performing a non-invasiveΒ sham surgery); and two of the trials wereΒ stopped early, which typically has the effect ofΒ overestimating the effect sizeΒ of the βtreatmentβ being studied. Readers will, of course, have to evaluate both the scientific criticisms and the defenses of the original trials to get a sense of the debate in this area, and draw their own conclusions.
Second,Β the African trials were carried out onΒ adult volunteersΒ rather than infants, which raises far fewer ethical concerns: not even the most fanatical of βintactivistsβ would argue thatΒ adult menΒ should be prohibited from having their own foreskins removed if that is what they desire. Finally, the studies wereΒ carried out in Kenya, Uganda, and South Africa, each of which has a very different epidemiological environment and disease profile than what is seen in countries such as the United States. For example, in Kenya, Uganda, and South Africa, the base rate of HIV transmission isΒ very high, and the virus is spread primarily through heterosexual contact. In places like the the U.S., by contrast, the base rate of HIV transmission is very low, and the virus is spreadΒ primarily throughΒ injective drug use and gay sex. Accordingly,Β even if we were to accept the findings from the African trials at face value, we would haveΒ no evidenceΒ that circumcision could be useful inΒ other parts of the world,Β let alone in infants, who are not susceptible to contracting HIV (unless they are molested).
What about the other STIs you mention? The latestΒ systematic review and meta-analysisΒ on this question reaches a conclusion very different from yours:
The claim that circumcision reduces the risk of sexually transmitted infections has been repeated so frequently that many believe it is true. In studies of general populations, [however], there is no clear or consistent positive impact of circumcision on the risk of individual sexually transmitted infections. Consequently, the prevention of sexually transmitted infections cannot rationally be interpreted as a benefit of circumcision, and any policy of circumcision for the general population to prevent sexually transmitted infections is not supported by the evidence in the medical literature.
Altogether, then, your citation of studies that show only benefits for circumcision (and your facile dismissal of those that point to the possibility of any downsides) is rather selective, to say the least. In fact, it reminds me of that very same βdevilishly clever sophistry dressed up as logicβ you referred to in your article.
You mention the term βgenital mutilationβ being used to refer to circumcision, and peg it to a βviolent mob of commentators.β I will say that I donβt much like the use of this term myself, as nobody likes to be told that theyβve been βmutilatedβ (among other reasons). But itβs worth mentioning that even thoughtful,Β sober legal scholarsΒ as well asΒ respected bioethicistsΒ have used the term βmutilationβ in this context as well β in part, no doubt, because certain forms of genital cutting that are actuallyΒ lessΒ invasive than male circumcision are unambiguously classified as βmutilationsβ by theΒ World Health Organization. This includes the βprickingβ of the clitoral prepuce of young girls (which does not remove any tissue and does not impair function, but which is neverthelessΒ federally bannedΒ in the United States). A fortiori, the argument goes, non-therapeutic circumcision of young males must also be a mutilation, since it removesΒ 1/3 or moreΒ of the motile skin system of theΒ penis.
Now, you do get some things right. The idea that the foreskin has βmythical powersβ is very silly indeed. It has no such powers. But it does consist ofΒ sexually sensitive tissueΒ (whose sensitiveness may certainly vary from male to male); it does serveΒ gliding and lubricatingΒ functions during sex, which does not seem inconsequential; and thus it might be at least reasonable to raise a question about the propriety of removing this tissue before the person whose penis it is has had a chance to make his own decision. InΒ medical ethics, irreversible surgeries of any kind are generallyΒ treated with great caution, especially when there is no disease or deformity present, and even more so when the patient is incapable of givingΒ consent.
So, no, circumcised men are not all damaged goods nor condemned to having terrible sex lives: that is clearly not the case, as circumcised men will generally attest. (Incidentally, some βcircumcisedβ females report that theyΒ enjoy their sex livesΒ as well, despite being told how βmutilatedβ they are by theΒ WHO). But some menΒ DO feel harmedΒ by their circumcisions, either because the operation was botched (which should be an impermissible risk for any non-consensual, non-therapeutic surgery), or because they feel violated in having had an erogenous part of their penis removed before they had an opportunity to sayΒ βnoβ.
Of course, if it were any other part of the body we were talking about in this regard, most people would find this to be a fairly reasonable emotional reaction.
Finally, you seem to misunderstand the meaning of the words βmedically unnecessaryβ β a term you attribute to those nutty βintactivistsβ in reference to non-therapeutic infant circumcision. Just because some health benefits may possibly ensue from removing a part of the body (and itβsΒ unclear that net health benefits even do ensueΒ in the case of circumcision, as discussed above), this does not make the surgery necessary, much less ethically sound. For example, we could eliminate breast cancer by removing the breast buds of all infant girls β and that would be an extraordinary medical benefit. However, infant prophylactic breast bud removal is not only βmedically unnecessaryβ but is quite clearlyΒ morally impermissible.Β Furthermore, UTIsΒ can be treated with oral antibioticsΒ (as they are for girls, who get themΒ 10 times more frequently), and STIs can be prevented by safe sex practices (as they are in Europe, where circumcision is rarely performed, and where STIs are, if anything, actually less of a public health concern). Of course, if an adult male would like to getΒ himselfΒ circumcised as a way to reduce his risk of becoming infected with an STIβdespite the fact that the evidence in this area is rather murky, and despite the fact that he would have to wear a condom either wayβthat is certainly up to him. Itβs quite a different matter, however, to remove healthy tissue from an infant based upon a rough guess about his future sexualΒ behavior.
In other words, if the βmedical benefitsβ in question can be obtained by less risky, less invasive, more autonomy-respecting means, then irreversible genital surgery without consent cannot be construed as being βnecessaryβ by even the wildest stretch of the imagination. The opposite of βnecessaryβ, of course, is βunnecessaryβ; hence the term βmedically unnecessaryβ used by βintactivistsβ.
In the final analysis, there can be no doubting that certain βfringeβ individuals take anti-circumcision arguments to extremes. But it would be a mistake to imply, as your article rather boisterously does, that the only people who are opposed to circumcision are βwackyβ activists β or, Iβm sorry, βwack-job intactivistsβ, as the Twitter manager forΒ SlateΒ magazine put it in the tweet* linking to your article. Instead, respected medical organizations including the Royal Dutch Medical Association (KNMG) have come out strongly against the practice, for many of the reasons I have already discussed. TheΒ KNMG states:
The official viewpoint of KNMG and other related medical/scientific organisations is that non-therapeutic circumcision of male minors is a violation of childrenβs rights to autonomy and physical integrity. Contrary to popular belief, circumcision can cause complications β bleeding, infection, urethral stricture and panic attacks are particularly common. KNMG is therefore urging a strong policy of deterrence. KNMG is calling upon doctors to actively and insistently inform parents who are considering the procedure of the absence of medical benefits and the danger of complications.
My best guess is that your views on circumcision are rather heavily informed by (and perhaps even constrained by) the default norms of American society, which sees non-therapeutic genital cutting** of boys to be an unremarkable affair. Your mostly-American readers, therefore, may happily lap up your attack on βintactivistsβ as being right on the money. But the US has aΒ very strange historyΒ in adopting circumcision as aΒ cultural norm, and the rest of the developed world views us*** with a mix of curiosity and disbelief. Why do Americans continue to circumcise their sons? Itβs not exactly crazy to take this questionΒ seriously.
Brian D. Earp
Research Fellow
University of Oxford
* Since deleted.
** Apologies for my βprogaganda-styleβ use of the term βgenital cuttingβ here, rather than βcircumcisionβ; I was looking for a synonym since Iβd already used βcircumcisionβ earlier in the sentence. Since βgenital cuttingβ is a medically accurate as well as value-neutral term, however, I thought this should be OK; and certainly it is a more descriptive choice than the Latin-derived βcircumcisionβ which rather euphemistically draws attention away from what it is that is actually being done.
*** Although my current affiliation is the University of Oxford, I am American, and was born and raised in the United States.