



Ignorant criticism Hounded by Anti-Circumcision Activists?



Reasoned response Here are the answers to their one-sided arguments!

UTC

Accusation:



Circumcision kills babies. Douglas Gairdner’s article in the British Medical Journal, published as long ago as 1949, proves that.



Rebuttal:



Gairdner’s research was inadequate. It wasn’t the circumcisions that killed the babies whose deaths he documented, it was the rudimentary anaesthetics used at that time. Nowadays general anaesthetics are only given to neonates needing emergency surgery, for example to correct a serious congenital heart defect necessitating immediate treatment. Circumcision does not require general anaesthesia; modern "local" anaesthetics are perfectly adequate. Therefore it can be done neonatally, safely and without pain.



“The boy who was raised as a girl”

David Reimer (1965–2004)

Accusation:



Circumcisions sometimes go wrong, as in the John/Jane case (



Rebuttal:



The fact that occasionally a procedure can go wrong is not a valid argument against the procedure itself, provided that it has some merits when the outcome is satisfactory. Rather, it poses a strong argument for the proper training and registered qualification of those carrying out the procedure.



A deeper academic consideration of unsatisfactory outcomes takes us into the areas of risk assessment, risk management and risk-benefit analysis. Most people are familiar with the concept of cost-benefit analysis, fewer appreciate the realities of risk-benefit analysis. Let’s consider the classic textbook example of falling down stairs: Most of us have fallen down stairs at one time or another. The majority will have walked away, shaken and perhaps bruised. Some will have been injured, sustaining broken arms, a broken hip, concussion or whatever. A few unfortunate individuals have died in such circumstances.



One possible action that would prevent all such adverse outcomes would be to abolish stairs, making every building single storey with ramped access. That would cure the problem. But by so doing we would lose all the advantages of multi-storey construction; more effective land use, cheaper construction per unit of floor area, better energy performance and so on.



Therefore we try to regulate, minimise and contain the risks posed by stairs. Good bannisters and handrails, a non-slip surface, adequate and constant tread width, a constant 'rise' between each tread, adequate lighting, baby gates in homes with young children and - crucially - risk awareness. How many times were you, at school, told not to run up or down the stairs? Risk management involves not only the creation of safe environments and safe procedures, but also sensible behaviour. The suggestion that circumcision should be banned because it involves risk is too simplistic. That’s analogous to banning staircases. The real issue here is how to make circumcision “safe” to acceptable standards in terms of risk-benefit analysis. Use by intactivists of an emotive, worst-case example is unhelpful here, a distraction from mainstream reality. Circumcisions sometimes go wrong, as in the John/Jane case ( David Reimer ). It is irresponsible to subject a child to an elective procedure that can have such a tragic outcome.The fact that occasionally a procedure can go wrong is not a valid argument against the procedure itself, provided that it has some merits when the outcome is satisfactory. Rather, it poses a strong argument for the proper training and registered qualification of those carrying out the procedure.A deeper academic consideration of unsatisfactory outcomes takes us into the areas of risk assessment, risk management and risk-benefit analysis. Most people are familiar with the concept of cost-benefit analysis, fewer appreciate the realities of risk-benefit analysis. Let’s consider the classic textbook example of falling down stairs:The suggestion that circumcision should be banned because it involves risk is too simplistic. That’s analogous to banning staircases. The real issue here is how to make circumcision “safe” to acceptable standards in terms of risk-benefit analysis. Use by intactivists of an emotive, worst-case example is unhelpful here, a distraction from mainstream reality.

Accusation:



Male circumcision is illegal in several countries, so you shouldn’t be promoting it.



Rebuttal:



Legislation to enforce training and exclude unqualified operators is not the same thing as a ban on the procedure itself. Regrettably, since the turn of the century a number of errors have been made in this regard in published articles and policy statements appearing in the medical press. Be especially wary of claims that male circumcision has been made illegal in South Africa, Sweden, Finland or New Zealand. It simply isn’t true.



When considering this issue, it is also necessary to make a distinction between illegality and administrative non-availability.

Accusation:



Cancer of the penis is very rare and no reason for "mass (routine infant) circumcision", even if one accepts that circumcision later in life does not confer the same protection against this particular form of cancer.



Rebuttal:



It certainly appears to be the case that the risk of contracting cancer of the penis in adult life is almost totally eliminated by neonatal circumcision but substantially unchanged by post-pubertal circumcision. Quite why that is so is not understood.



Regarding the incidence, our resident statistician writes: [Such cancers] are very rare in countries where most of the male population is circumcised. If all the North American males alive today were uncircumcised one would expect around 173,000 to suffer cancer of the penis at some stage of their lifetime. All would undergo partial or complete amputation of the penis and about half would die as a direct result of the cancer. This might not seem very large as a percentage, but it is an awful lot of men.



The figure of 1 in 1000 is a median one. Canadian statistics suggest as high as 1 in 600, Australian ones as low as 1 in 1500. One must also bear in mind that circumcision is a multi-benefit procedure. The choice between circumcision and non-circumcision does not (or, at least, should not) rest on this one issue of cancer of the penis. To correctly assess the merits of circumcision it is necessary to add up all the benefits of the procedure and consider the total, not pick off individual benefits for criticism one at a time. Cancer of the penis is very rare and no reason for "mass (routine infant) circumcision", even if one accepts that circumcision later in life does not confer the same protection against this particular form of cancer.It certainly appears to be the case that the risk of contracting cancer of the penis in adult life is almost totally eliminated by neonatal circumcision but substantially unchanged by post-pubertal circumcision. Quite why that is so is not understood.Regarding the incidence, our resident statistician writes:One must also bear in mind that circumcision is a multi-benefit procedure. The choice between circumcision and non-circumcision does not (or, at least, should not) rest on this one issue of cancer of the penis. To correctly assess the merits of circumcision it is necessary to add up all the benefits of the procedure and consider the total, not pick off individual benefits for criticism one at a time.

Accusation:



Taken together, the clinical benefits to a child during childhood do not merit making the circumcision decision a parental choice. Leave him to decide once he becomes responsible for his own healthcare choices.



Rebuttal:



The principal responsibility of parenthood is to act at all times in the child’s best interests. Amongst many other things, that creates an obligation to take medical decisions that the child, by virtue of age, cannot comprehend.



Some benefits of circumcision are lost if elective circumcision is deferred until adulthood. These are: Greater expense in consequence of the greater complexity of the procedure post-puberty





Requirement for initiative and determination to arrange a circumcision





Slower to heal





Implications of time off work or school





Probability of a less satisfactory cosmetic outcome





No benefit in terms of protection against infant urinary tract infections and the attendant risk of kidney damage





No benefit in terms of protection against cancer of the penis later in life





Risk of greater exposure to sexually transmitted diseases if onset of sexual activity precedes circumcision (There may, in addition, be good cause to circumcise a child for therapeutic medical reasons, but that’s a different issue.)



Aside from any suspicions that the argument in favour of deferral is actually a covert argument against circumcising at all, CIRCLIST suggests that the existence of these additional benefits of neonatal circumcision do justify the matter being decided by parents. Note that the above list identifies additional benefits; neonatal circumcision also conveys all the same benefits as adult circumcision. Taken together, the clinical benefits to a childdo not merit making the circumcision decision a parental choice. Leave him to decide once he becomes responsible for his own healthcare choices.The principal responsibility of parenthood is to act at all times in the child’s best interests. Amongst many other things, that creates an obligation to take medical decisions that the child, by virtue of age, cannot comprehend.Some benefits of circumcision are lost if elective circumcision is deferred until adulthood. These are:(There may, in addition, be good cause to circumcise a child for therapeutic medical reasons, but that’s a different issue.)Aside from any suspicions that the argument in favour of deferral is actually a covert argument against circumcising at all, CIRCLIST suggests that the existence of these additional benefits of neonatal circumcision do justify the matter being decided by parents. Note that the above list identifiesbenefits; neonatal circumcision also conveys all the same benefits as adult circumcision.

Accusation:



Circumcision of children is immoral and unethical because it is an elective body modification that is, for practical purposes, irrevocable. Leave the child alone until he is old enough to decide for himself.



Rebuttal:



This accusation implies the existence of an over-riding moral and ethical block on any recommendation to circumcise implied by the risk-benefit analysis. It sets up what a CIRCLIST correspondent once described as “a collision between the irresistible force of scientific reason and the immovable object of moral objection”.



So who is right?



The scientific reason is entirely objective (factual), whereas the moral objection is purely subjective (an opinion). The problem with the intactivists’ stance is that they seek to impose their opinion on others, in the process inflating the magnitude of their moral objections to a level akin to that seen in debates about abortion or euthanasia. Circumcision really isn’t that big an issue. Thus CIRCLIST says: Circumcision should neither be made compulsory nor illegal. The decision whether or not to circumcise a baby boy is, quite properly, a decision to be taken by the family in the context of their individual circumstances. That said, it seems perfectly right and proper for the state to make strong recommendations in favour of circumcision, especially in instances where a socialised medical care system exists such that the long-term financial burden of non-circumcision falls on the state.





Professionals directly involved in implementation should stand aside from the public debate.





Advice given by professionals involved in counselling parents should be wholly factual, free from value judgements. In the absence of generally accepted medical contra-indications, the advice should also be free from recommendations or vetoes.





Individual professionals with a moral objection to infant male circumcision should not block a requested service, but can properly avoid personal participation by referring the matter to another practitioner who is known to be willing to act.





Campaigners against circumcision should respect the right of others to hold an opinion that differs from their own and should refrain from vilifying those who carry out, research or publish the benefits of the procedure. All said and done, the moral issue is purely a matter of opinion. It is something that does not lend itself to objective analysis. Circumcision of children is immoral and unethical because it is an elective body modification that is, for practical purposes, irrevocable. Leave the child alone until he is old enough to decide for himself.This accusation implies the existence of an over-riding moral and ethical block on any recommendation to circumcise implied by the risk-benefit analysis. It sets up what a CIRCLIST correspondent once described as “a collision between the irresistible force of scientific reason and the immovable object of moral objection”.So who is right?The scientific reason is entirely objective (factual), whereas the moral objection is purely subjective (an opinion). The problem with the intactivists’ stance is that they seek to impose their opinion on others, in the process inflating the magnitude of their moral objections to a level akin to that seen in debates about abortion or euthanasia. Circumcision really isn’t that big an issue. Thus CIRCLIST says:All said and done, the moral issue is purely a matter of opinion. It is something that does not lend itself to objective analysis.

Accusation:



There’s no such thing as phimosis in infancy. The foreskin is not intended to be retractable at that time.



Rebuttal:



This involves a false interpretation of the term ‘phimosis’. Correctly used, phimosis means that the opening at the tip of the foreskin is too small (full stop, no further qualification!). Phimosis is present in an infant if the opening in the tip of the foreskin is too small to allow micturition without pain, back pressure or ballooning. The word is not an synonym for adhesions between the inner foreskin and the glans.

Accusation:



Phimosis only occurs when the male is suffering from BXO. Any diagnosis of phimosis in the absence of BXO must, therefore, be false. No BXO, no reason to circumcise.



Rebuttal:



The accusation here reverses cause and effect. BXO does not cause phimosis. What’s really happening is that phimosis (opening at the tip of the foreskin too small - see above) is producing an environment conducive to either Balanitis or its auto-immune form BXO. Circumcision of a phimotic foreskin prevents the problem before it arises.

Accusation:



There’s no such thing as redundant foreskin. The foreskin is a naturally-occurring body part.



Rebuttal:



A redundant foreskin ( IE one that is excessively long) can make successful intercourse almost impossible. If this isn’t good cause for elective medical intervention, what is? This condition is a developmental abnormality, normally observable pre-puberty. It should be dealt with then, for the simple reason that circumcision is easier to perform before the onset of secondary sexual development.

Accusation:



The only valid medical reason to circumcise is paraphimosis. Even phimosis doesn’t merit it; the foreskin can be stretched and/or treated with steroidal creams.



Rebuttal:



Foreskin stretching is not a sure-fire way of curing phimosis. Indeed, it can be counter-productive. By inducing micro-tears in the prepuce, stretching can promote the formation of scar tissue. Scar tissue being less elastic than normal tissue, this makes the situation worse. Note that the micro-tears can be wholly within the foreskin; an absence of visible bleeding is no guarantee that such an adverse result is not in the course of being produced.



Steroidal creams are somewhat questionable. Many are carcinogenic. There is no guarantee that they will have the intended effect. Circumcision produces a more predictable result without introducing the long-term uncertainties associated with steroids.



Additionally, circumcision provides all the other benefits detailed on this website. It is certainly true that, in some instances, other remedies or forms of prophylaxis are available. Smegma can be controlled by frequent, diligent washing. Some HPV infection risks can be mitigated by use of a vaccine. But the big advantage of circumcision is that it achieves these things - and more - in one hit. Done in infancy, it is one simple and low-risk procedure needing no long term follow-up.

Accusation:



The foreskin is erogenous tissue, containing many thousands of nerve bundles associated with sexual pleasure. Removing it decreases enjoyment of the sex act.



Rebuttal:



This is a myth not substantiated by the evidence. Men circumcised as adults, who have had sexual experience both before and after circumcision, generally report an improvement in their sexual pleasure.

Accusation:



The pro-circumcision lobby often recommend removal not only of the foreskin but also of the frenulum. That’s packed with nerve endings, so doing away with it must reduce sexual sensation.



Rebuttal:



When it comes to frenulum removal, it is clear that there are several different possible starting points depending on the individual’s anatomy. Not every frenulum is the same.



Taking (as we must, on histological evidence) that the sensitive nerve endings are in the shaft just beneath the frenulum rather than in the web of tissue itself... A tight, restrictive frenulum prevents these nerve endings (genital corpuscles) getting much sensation, so the area is insensitive before circumcision. Circumcision with frenulum removal lets them get stimulation and ... wow! There is an explosive improvement in sensation.

A loose, relaxed frenulum makes the area very sensitive before circumcision. If, after circumcision, there is a lot of scar tissue and/or surplus skin in the area, some of this sensation is lost.

Consider again the loose, relaxed frenulum that makes the area very sensitive before circumcision. If the circumcision creates a tight, thin skin where the frenulum had been that makes it even more sensitive. [The personal experience of the contributor of this comment - Editor]. So there is no simple answer. It comes down to individual anatomy before circumcision and how the operation is done. The key issue is to avoid the creation of scar tissue. Evidence of a tendency towards keliod scarring in the individual patient might well be considered as a contra-indication to frenulum removal, but otherwise the criticism of the procedure on the grounds of loss of sexual sensitivity seems ill-founded. The pro-circumcision lobby often recommend removal not only of the foreskin but also of the frenulum. That’s packed with nerve endings, so doing away with it must reduce sexual sensation.When it comes to frenulum removal, it is clear that there are several different possible starting points depending on the individual’s anatomy. Not every frenulum is the same.Taking (as we must, on histological evidence) that the sensitive nerve endings are in the shaft just beneath the frenulum rather than in the web of tissue itself...So there is no simple answer. It comes down to individual anatomy before circumcision and how the operation is done. The key issue is to avoid the creation of scar tissue. Evidence of a tendency towards keliod scarring in the individual patient might well be considered as a contra-indication to frenulum removal, but otherwise the criticism of the procedure on the grounds of loss of sexual sensitivity seems ill-founded.

Accusation:



The USA has one of the highest rates of circumcision in the non-Muslim world, yet it also has an HIV/AIDS epidemic. This proves that circumcision doesn’t prevent AIDS - it may even show that it causes it.



Rebuttal:



Most transmission of the HIV virus in the USA occurs due to needle-sharing by drug abusers or as a result of homosexual relations involving sodomy. Rather obviously, circumcision will make no impact whatsoever in the needle-sharing scenario. Whilst there may be some minor protective effect during anal intercourse, that act is more likely to produce lesions (small tears) in the skin than is the case with vaginal intercourse, resulting in the direct exchange of body fluids and thus the transfer of the virus that causes AIDS.



Where circumcision does have a statistically significant protective effect is in preventing female-to-male transfer during vaginal intercourse. This means that male circumcision will be most effective (as regards slowing the spread of HIV) in societies where men regularly have sex with a number of different females.

Accusation:



If the white medical professionals involved in the circumcision campaigns going on in Africa truly believe in the HIV and STD preventative benefits of mass circumcision, why do they not do the same in their home countries?



Rebuttal:



To put things bluntly, there is a significant difference between the population groups as regards rates of promiscuity. Many African cultures condone (and some expect) that a man will visit a prostitute during his wife’s menstrual period. This is the prime reason why campaigns of mass circumcision are more effective in sub-Saharan African heterosexual context than would be the case in (say) Europe. The pattern of risk exposure is different. However, this does not mean that circumcision has no place in European culture, merely that the ‘payback’ is less on a population-wide basis. Note that the degree of protection conferred to an individual by circumcision remains the same.

Accusation:



Condoms are more effective at preventing the transmission of STIs (sexually transmitted infections) than circumcision. So don’t circumcise, use a condom.



Rebuttal:



Several points here... Circumcision is a one-off procedure giving lifelong protection, albeit only partial, to an at-risk individual. No matter if the man is drunk, or whisked off his feet in a moment of passion - the protective effect of his circumcision remains in place. Not so where condoms are the sole means of protection; each time an uncircumcised man neglects to use a condom he is in a higher risk situation than his circumcised counterpart.



In many parts of the world, supplies of good quality condoms are both scarce and expensive. In hot countries, stocks deteriorate more rapidly and soon reach their “use by” date. This, and the length of the supply chain, make condoms expensive in precisely the countries where they are most needed. In parts of Africa, a condom costs more than a prostitute. Even then there is no guarantee that the product in the package is genuine; condom manufacture is as susceptible to brand piracy as any other commodity.



The effects of the two forms of protection are cumulative. Both together give better protection than either one alone. The answer, both in terms of individual health protection and the wider considerations of curbing epidemics, is to double up on the protection. Don’t treat this as an either/or matter; circumcise and use a condom. Condoms are more effective at preventing the transmission of STIs (sexually transmitted infections) than circumcision. So don’t circumcise, use a condom.Several points here...The answer, both in terms of individual health protection and the wider considerations of curbing epidemics, is to double up on the protection. Don’t treat this as an either/or matter; circumcise and use a condom.

Accusation:



Circumcision creates a false sense of security. It isn’t perfect protection against sexually transmitted infections and it will cause people to neglect other precautions.



Rebuttal:



This most certainly is a theoretical possibility, one that needs to be addressed through education. Fieldwork amongst males circumcised as adults shows that some individuals do act in this irresponsible way, but they are in a minority small enough not to negate the public health benefit of circumcising the more responsible majority.

Accusation:



Circumcision isn’t necessary to prevent sexually transmitted diseases. The same effect can be achieved by chastity and marital fidelity. In other words, by keeping one’s zipper shut.



Rebuttal:



Er, yes. If both parties to every marriage were virgins and neither ever committed adultery... If neither carried the HIV virus from birth, or as a result of breast-feeding from an infected mother... If neither had received contaminated blood products at any time...



Can we remain in the real world, please? There is a deadly virus on the loose, the spread of which can be slowed by a number of very different means. We need to use every technique available to disrupt transmission of the virus. Those who advocate a puritanical lifestyle need to realise that they are in a minority; their cultural aspirations simply won’t have a meaningful impact on the problem of the HIV/AIDS epidemic. That said, if they themselves maintain their own standards, they will lower their personal risk to near zero. But whilst it will work for them, it won’t work for others who do not share their self-dicipline.



“Oh, but if only...!” isn’t good enough.

Accusation:



Circumcision is only for Jews and Muslims.



Rebuttal:



Why the presumption that, because these groups circumcise for religious reasons, others should not? Nobody here at CIRCLIST is suggesting getting circumcised as a way of joining either faith. Circumcision has undoubted merits on purely secular grounds and would benefit from being de-coupled from issues of religious affiliation.

Accusation:



We don’t circumcise animals, so why circumcise humans?.



Rebuttal:



Foreskins are unique to humans; other mammals have something properly termed a ‘penis sheath’. Our evolutionary divergence may well date from the time when our ancestors first walked upright, a posture less likely to expose the penis to mechanical damage. Our unique anatomy has, unfortunately, produced a unique set of problems. But human ingenuity has also produced a solution - circumcision.





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Acknowledgements



Photo of David Reimer, raised as Brenda, courtesy of the British Broadcasting Corporation. The original is believed to come from the archives of the school attended by ‘Brenda’. The following resources were used in the preparation of this web page:

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