I thought I would try to find a topic that has not been, to my knowledge, extensively explored in skeptical literature, and settled on male circumcision because it is a "traditional practice" reflective of an "entrenched belief system." In tackling this subject I will attempt find putative "scientific" studies that argue for and against the practice, and point out where these studies fall short or seem to be excessively dependent on shoddy methodology or beholden to partisan religious beliefs.
Wikipedia defines circumcision as "the surgical removal of the foreskin (prepuce) from the human penis," a definition that I think is fine for the scope of this essay. Circumcision appears to be the oldest "planned medical procedure" and today is mostly associated with the religious practices of Jews and Muslims. The World Health organization estimates that approximately 30% of males over the age of fifteen are circumcised, and almost 70% of these are Muslims.
Jews and Muslims ostensibly follow the process of circumcision because it is set down in the Hebrew Bible, specifically Genesis 17: 9-14, in which Abraham and his sons are circumcised as part of a covenant with God.
Then God said to Abraham, “As for you, you must keep my covenant, you and your descendants after you for the generations to come. This is my covenant with you and your descendants after you, the covenant you are to keep: Every male among you shall be circumcised. You are to undergo circumcision, and it will be the sign of the covenant between me and you. For the generations to come every male among you who is eight days old must be circumcised, including those born in your household or bought with money from a foreigner—those who are not your offspring. Whether born in your household or bought with your money, they must be circumcised. My covenant in your flesh is to be an everlasting covenant. Any uncircumcised male, who has not been circumcised in the flesh, will be cut off from his people; he has broken my covenant.”
The roots of God's command may perhaps be found in the institution of slavery. Peter Charles Remondino in his History of Circumcision (1891) "suggested that it began as a less severe form of emasculating a captured enemy: penectomy or castration would likely have been fatal, while some form of circumcision would permanently mark the defeated yet leave him alive to serve as a slave." Though an interesting suggestion, there appears to be no way to prove this idea.
Remondino's book was last printed in 1974, and his position that circumcision could cure or prevent "alcoholism, epilepsy, asthma, hernia, gout, rheumatism, curvature of the spine and headaches" was accepted as fact by doctors. According to Marilyn Fayre Milos, RN and Donna Macris, CNM, MSN, in "Circumcision: A Medical or a Human Rights Issue?” (http://www.cirp.org/library/ethics/milos-macris/) "As scientific advancements found legitimate pathologic etiologies for diseases previously believed to be prevented or cured by circumcision, new excuses were adopted to substantiate this elective genital surgery. Since the turn of the century, one excuse after another has been used to perpetuate a practice most of the world has never considered." Science, it seems, was being used as an excuse to justify circumcision.
Over the years it has been postulated that circumcision improves hygiene, prevents venereal disease, prevents penile and cervical cancer, protects against urinary tract infections, and even today is believed to decrease the chances of contracting AIDS. However, the reasons for the continued prevalence of circumcision seem to be religious and cultural. One woman I know told me that she did not want her son to feel ostracized by having a different looking penis, while others balk at the thought of breaking with strong religious and family traditions.
Still, in 1975 the American Academy of Pediatrics concluded, "There is no absolute medical indication for routine circumcision of the newborn" and later the American College of Obstetricians and Gynecologists concurred. However, by 1999 the AAP decided to take a "neutral" stance on circumcision and still later in 2012 advanced a report that that posits some benefits in the reduction of HIV (40-60%) for heterosexual sex. There is no reduction in risk noted for homosexual encounters. (http://www.nytimes.com/2012/08/27/science/benefits-of-circumcision-outweigh-risks-pediatric-group-says.html)
So what is the verdict on circumcision? Unfortunately both sides of the debate rely on pseudo-science to make their case. Dan Bollinger, a prominent opponent of circumcision, claims 117 boys die each year due to circumcision, yet the CDC noted no circumcision related deaths in 2010. Bollinger gets his number through bad science and flawed assumptions. The blog Circumcision News checked out Bollinger's methodology, and found it wanting. (http://circumcisionnews.blogspot.com/2010/05/fatally-flawed-bollingers-circumcision.html) For one thing, Bollinger assumes that the higher rate of male infant mortality (when compared to females) is almost completely due to botched circumcisions. This is patently absurd.
On the other side of the issue, however, there is also a kind of pseudo-science, or at least a lack of willingness to follow where the science seems to lead. Dr. Douglas S. Diekema, a member of the AAP's task force of circumcision has said, “There’s no compelling medical reason to do it. There’s also no compelling reason that it’s not a valid choice for families to make. There are some small benefits and these need to be weighed against the risks.”
So is this entire issue simply about a cosmetic alteration to male genitalia, as miner an issue as piercing a baby's ears? If circumcision is a medically neutral procedure, then it seems that the AAP, in taking no position on what essentially amounts to cosmetic surgery performed on infants, is violating the tenet of "First, do no harm." This neutral position ignores the testimony of men who have experienced a sex life both with and without a foreskin. Milos and Macris cite the following:
"I was deprived of my foreskin when I was 26. I had had ample experience and was happy with the pleasure I could experience as an intact male. After my circumcision, that pleasure was utterly gone. Let me put it this way: On a scale of 10, the intact penis experiences pleasure that is at least 11 or 12; the circumcised penis is lucky to get to 3. If American men who were circumcised at birth could know the deprivation of pleasure that they would experience, they would storm the hospitals and not permit their sons to undergo this unnecessary loss."
It took no time at all to find other stories of men realizing a greatly reduced amount of sexual pleasure post circumcision. Blogger David Louis writes, "I had disgust with the surgeon for failing to warn me, and disgust with myself for letting this happen, and an overall feeling of bitter bitter disappointment of the loss of sexual feeling. Now, 30 months on, the foreskin removal is a horrendous loss to me and my sexual enjoyment." (http://davidlouis77.wordpress.com/2010/05/08/adult-circumcision-my-experience-2-years-on/)
As compelling as these stories are, I can find no studies that address the issue of decreased sexual pleasure post circumcision. As most circumcisions are performed well before the child comes of age, circumcised men can never know what they are missing, if indeed they are missing anything.
There is a possibility that this issue is too charged because of religion, culture, tradition and even perhaps a bit of institutional reticence on the part of the so-called "medical establishment" to rock the boat. If the AAP were to come done conclusively against circumcision, would young men be justified in suing their doctors for inflicting unnecessary surgery?
Until very recently, the idea that babies experience pain due to circumcision has been ignored. Almost all circumcisions in the world were routinely done with any kind of pain relief for the infant. No one doubts that circumcision causes extreme pain in infants. Though unable to articulate their pain babies show signs of increased blood pressure, increased heart rate, decreased oxygen in the blood, and a surge of stress hormones. In most industrialized nations anesthetics are now routinely used during and after circumcisions.
Isn't subjecting newborns to extreme pain a violation of medical doctrine? Science clearly indicates that babies suffer extreme pain due to circumcision, yet still the AAP maintains a mostly neutral position.
What data there is certainly seems to mitigate against infant circumcision, yet this data is ignored. Instead, proponents appeal to cultural, religious and traditional norms. Opponents counter with even more evidence of circumcision's harm, even where none seems to exist. The issue is polarizing and both sides quickly jump on any new study that can justify their opinion, critically examining those that run counter to their position and naively popularizing even flawed studies that support them.
The question of circumcision then, falls squarely into the realm of pseudo-science, at least when it comes to processing the various arguments for and against it. The studies we have are tantalizing and interesting, but just how real cost-benefit analysis can lend itself to experimentation and prediction remains elusive.
Thursday, October 3, 2013
Circumcision and Pseudo-Science
An essay I wrote as part of my class at the Humanist Institute on :
at 1:13 PM