Intactivist claims, articles & videos debunked
In this section we debunk some intactivist claims and arguments that do not neatly fall into the categories covered in other parts of this website, or entire intactivist articles and videos.
- Claim: Long term psychological effects of circumcision
- Debunking anti-circumcision pseudoscience – replying to the open letter to Bill Gates
- Why not remove the breast buds (or appendix, etc.)?
- MRI scans and circumcision brain damage?
- Brian Earp, Robert Darby and the not so sceptical “Skeptic”
Claim: Long term psychological effects of circumcision
One of the most often-made accusations/arguments against circumcision (and a favorite scare tactic used by those opposed to the procedure) is that circumcision of infants is psychologically traumatizing and has long-term negative psychological effects on their development and behavior.
There have been several scientific studies done during the past decade or so clearly showing that there is no credible scientific evidence that circumcision as a procedure is traumatizing to the infant or child, and relating circumcision with any long term negative effects. The most recent study was published in the Journal Translational Psychiatry in March 2017. The article concluded that:
“Male circumcision in Jewish individuals shows no changes in neurobiological (glucocorticoids) and psychometric (depressiveness, anxiety, physical complaints, resilience and SOC) markers of TSRDs (trauma- and stressor-related disorders). A healthy functionality of the LHPA axis has been proven. In regard to clinical implications, the present study shows that measuring physical activity in association with glucocorticoid hormones in hair concentrations provides a suitable method for the determination of stress-related activity in the LHPA axis. Furthermore, persistent glucocorticoid hormone concentrations in hair samples are a cost-effective and non-invasive method. Recording the long-term hair glucocorticoid concentrations should be routine in TSRD diagnostics. Furthermore, the construct of ambivalence should be used to accomplish more empathy and mutual understanding among the opposing parties in the discussion”. For an online link to the complete article, see here.
Another recent scientific study has stated that “our findings provide evidence that male circumcision does not promote psychological trauma. Moreover, a qualitative approach, the ambivalence construct, was used for the discussion, aiming at a discourse devoid of biases.” From the abstract :
“Male infants and boys through early adolescence can undergo circumcision either for the sake of upholding reliious traditions or for medical reasons. According to both, Jewish as well as Islamic tenets, circumcision is a religious rite symbolizing the bond with God. The World Health Organization (WHO), the United Nations Council (UNC) as well as the American Academy of Pediatrics (AAP), and the Centers for Disease Control and Prevention (CDC) strongly recommend circumcision to promote hygiene and prevent disease. This procedure has frequently been criticized by various communities claiming that circumcision in infancy and early adolescence were psychologically traumatizing with medical implications up into old age. Due to the lack of evidence concerning an alleged increase in vulnerability, we measured objective and subjective stress and trauma markers, including glucocorticoids from hair samples, in circumcised and non-circumcised males. We found no differences in long-term limbic-hypothalamic-pituitary-adrenal axis activity, subjective stress perception, anxiety, depressiveness, physical complaints, sense of coherence and resilience. Rather, an increase in the glucocorticoid levels indicated a healthy lifestyle and appropriate functioning. Thus, our findings provide evidence that male circumcision does not promote psychological trauma. Moreover, a qualitative approach, the ambivalence construct, was used for the discussion, aiming at a discourse devoid of biases.”
The online abstract and authors’ list can be found here.
Related arguments are that circumcision causes autism (false, see: http://circfacts.org/medical-benefits/risks-complications/#risk2) and that it causes brain damage as revealed by MRI scan (a suspected hoax, see: http://circfacts.org/debunking-corner/#debk4)
Debunking anti-circumcision pseudoscience – replying to the open letter to Bill Gates
An annotated version of the National Coalition for Men’s letter to the Bill and Melinda Gates Foundation
Published: Aug. 16, 2014, 3:30 p.m., Last updated: Aug. 16, 2014, 4:31 p.m. (originally published online here).
The National Coalition For Men (NCFM) published a letter to the Gates Foundation dated 14 July that argues against circumcision as an HIV-prevention measure in sub-Saharan Africa. The letter was written by Peter Adler and Steven Svoboda and submitted by the NCFM’s president, Harry Crouch. Stephen Moreton has annotated the NCFM letter, pointing out its errors. This is a slightly edited version of the annotations he has sent to the Gates Foundation.
The NCFM text submitted by Harry Crouch is in italics. The annotations by Stephen Moreton are in bold.
Everyone should applaud how your Foundation is funding proven methods to slow the spread of HIVand AIDS in sub-Saharan Africa, including testing, teaching the so-called ABC’s (Abstinence, Be Faithful, and Condoms), retroviral therapy, treating schistosomiasis (which causes vaginal bleeding) and STDs, and helping to lead the search for an HIV vaccine. It is time, however, for your Foundation to stop funding the scientically, morally, ethically, and legally unjustified program to circumcise 38 million African men as an HIV preventive strategy. After seven years and 6 million circumcisions, your program has failed.
On the contrary, it is working. See Auvert et al, 2013.
The mass male circumcision program is being justified based on four random controlled trials (RCTs) conducted in sub-Saharan Africa. The RCTs suffered from numerous ethical, scientific and methodological flaws that render the results meaningless. [1, 2]
Here the author ignores multiple debunkings of these criticisms. They have been answered in painstaking detail by authorities in the field, and to the satisfaction of all professional bodies involved. For examples of comprehensive debunkings see Halperin et al. (2008) and Morris et al. (2012). Tellingly, some of the articles cited in the open letter at this point attracted debunkings specific to those articles. Thus Green et al. (2010) in ref. 2 was refuted by two separate letters to the editor: Banerjee et al. (2011) and Wawer et al. (2011); Boyle & Hill (which the author neglects to provide the full reference for) were refuted by Wamai et al. (2011); and Van Howe & Storms (2011) in ref. 2 were refuted by Morris et al. (2011). Ignoring criticisms, and citing discredited studies, is a pattern in Harry Crouch’s open letter, as we shall see.
Worse, one of the RCTs produced evidence that was quickly buried suggesting that circumcision may increase male to female transmission of HIV by 61%. 
The reference given (no. 3) merely refers the reader to the list of discredited studies above it, leaving the reader with the tedious task of searching through them to find the primary source. (Bad referencing is a problem with this open letter). Presumably it is Wawer et al. (2009) who found that the female partners of recently circumcised HIV positive men had a higher risk of becoming positive themselves. This was because some men resumed sex before they had completely healed. So it is really an argument for educating men about the need to wait for complete healing before resuming sex, rather than an argument against circumcision per se.
Moreover, the African circumcision program may be completely unnecessary, as a Ugandan RCT  showed that intact men who wait at least ten minutes to clean their penis after sexual intercourse are 41% less likely to contract HIV than circumcised men. 
Here the author refers to a study which found that men who were quick to wash themselves after intercourse were more at risk than those who took their time and eventually merely wiped themselves with a cloth. Intactivists have enthusiastically seized on this curious finding and promoted it as an HIV-prevention strategy. This is premature as it is not proven why waiting and wiping should be of benefit. Speculations about enzymes in vaginal fluids have been made but the truth may be far more mundane. If a man has sex with a stranger, a prostitute, or someone else he considers to be at high risk of having HIV, then he will be far more likely to wash thoroughly and quickly as soon as proceedings have concluded. On the other hand, if he is with his regular partner, or someone he knows to be at low risk, he will be relaxed, and may take some time before merely reaching for a cloth and drying himself off. In short, the difference is simply a reflection of the accuracy of the men’s perception of risk (Ndebele et al., 2013). In light of this simple, prosaic explanation, it is reckless and irresponsible to promote “wait and wipe” as an HIV prevention strategy.
Thus, the program’s targets could be achieved without a single circumcision and at minimal cost versus a projected cost for the current program of $16 billion. African men and women should have been informed of these facts critical to their health and safety.
As the author’s basis for this comment comprises discredited studies and an irresponsible instruction about waiting and wiping, it can be dismissed. What the author is presenting is not factual at all, but dangerously misleading pseudoscience.
Circumcision Offers Men Little or No Protection From HIV.
Circumcision results in about a 60% reduction in female to male transmission as indicated by three randomized controlled trials, rising with time to around 76% in the South African trial.
Some Africans are being told, and many will reasonably assume (why else are they being circumcised?) that circumcision will protect them from HIV, but that is false. Circumcision is no vaccine. Circumcised or not, men who have sex with HIV infected females risk becoming HIV positive. Africans should be informed as follows: “For highly exposed men, such as men living in southern Africa, the choice is either using condoms consistently, with extremely low risk of becoming infected, or being circumcised, with relatively high risk of becoming infected.” 
Getting men to use condoms consistently has proved challenging despite massive condom promotion. Circumcision provides added protection for when condoms fail (as sometimes they do) and for those who don’t or won’t use them. The reference cited (no. 6) refers one to no. 5 above, which is a duplicate of no. 4, and is not the source of the quote. More sloppy referencing. Presumably it is intended to be Garenne (2006).
Even if circumcision did reduce the relative risk by 50%, Garenne concluded,“ a 50% reduction in risk [if true] is likely to have only a small demographic effect. “Observational studies of general populations have for the most part failed to show an association between circumcision status and HIV infection.” 
Again the reference is wrong. In fact it comes from Van Howe and Storms (2011) in ref. 2 which, as explained previously, was discredited by Morris et al. (2011).
Thus, the true protection that circumcision provides to men from HIV infection is negligible or nil. 
False, for reasons stated above.
Ironically, Circumcision Will Likely Increase HIV Infections Among African Men and Women. Experts have concluded that “circumcision programs will likely increase the number of HIV infections.” 
The reference given here is to husband and wife Van Howe and Storms, although confusingly it says “Supra n.12” which means “note 12 above”, when 12 is actually below. It should be n.2. Such repeated careless referencing does not inspire confidence in the author’s academic skills. And, as Van Howe and Storms have no relevant research background in African HIV, but are in fact prominent intactivists, and Van Howe has a history of shoddy scholarship (see below), the description of them as “experts” is misleading. As stated before, the article in question has been debunked (Morris et al., 2011). Some of the co-authors of the debunking were involved in the African trials – real experts.
First, only 30%-35% of HIV in African men is attributable to sexual transmission, not 90% as experts initially claimed.  HIV in Africa is often blood borne, spread by contaminated needles.
Once again the author makes a bogus claim from a discredited source. In this instance he cites Gisselquist whose ideas about African HIV being mostly spread by vaccinations were thoroughly debunked in 2004 by the WHO (Schmid et al. 2004). Gisselquist continues to be cited by anti-vaccination groups, HIV/AIDS deniers and, it seems, intactivists, but among the scientific community he has no credibility.
Circumcision surgery in Africa often causes HIV.
Having been regaled with discredited studies, and fringe sources like Gisselquist, we now have the other stock-in-trade of the pseudo-scientist – the half-truth. Traditional African-style circumcision with a razor blade and no regard to hygiene, pain control or cosmetic outcome, can spread HIV. This has been known for years (e.g. Brewer et al. 2007) and might explain why in some African countries (e.g. Lesotho, Cameroon & Tanzania) circumcision actually correlates with HIV (something intactivists never tell their audiences when they gleefully point to such countries).
The problem will [be] much worse when millions of Africans are circumcised in multiple, often un-sterile venues on a rush basis by poorly trained workers.
Then see that they are trained and have the time and resources to do the job properly.
Second, volunteers, reasonably believing that they are completely or substantially protected from HIV, are less likely to use condoms, [11,12] and circumcised men are less likely to use condoms anyway.
This is the “risk compensation” argument. As usual the references cited are both discredited studies by the unreliable Robert Van Howe. No. 12 in particular became a textbook example – literally – of how NOT to do a meta-analysis (Borenstein 2009). Undeterred, Van Howe went on to do a second meta-analysis (on circumcision & HPV) that was so bad that when experts from the Catalan Institute of Oncology examined it they concluded it ought to be retracted from the literature (Castellsagué et al 2007). But Van Howe didn’t learn and when his third meta-analysis came out (on circumcision & STIs) it was again found to be so bad as to merit retraction (Morris et al. 2014). Whenever Van Howe gets on his anti-circumcision hobby-horse he attracts criticisms. These episodes are just a sampling of the impressive tally of rebuttals and critiques he has clocked up over the years. And he was described earlier in Crouch’s open letter as an “expert”! Readers are advised to be deeply wary of anything bearing the name Van Howe.
Of course the notion of risk compensation has already been well examined and found not to be an issue when men are given proper counseling. Here are the studies demonstrating this which Crouch ignores: Mattson et al. (2008), Reiss et al. (2010), L’Engle et al. (2014), Westercamp et al. (2014).
Third, mass circumcision diverts resources from the proven methods of HIV prevention listed in the introduction. Thus, your mass male circumcision program will not only fail but will backfire.
Circumcision Is Also Painful, Risky, and Harmful. Africans report surprised at how painful circumcision is. Even if local anesthetics are used and given time to work, they are largely ineffective, and pain continues during the healing period.
This is just false as millions of men circumcised in this way know. Where is Crouch’s evidence?
Even the American Academy of Pediatrics ‘Task Force on Circumcision concedes that circumcision risks a long list of minor injuries, serious injuries (including hemorrhage, infection, deformed penis, and loss of all or part of the glans or of the entire penis) and death. In the United States, the risk of injury is estimated to be between 2% and 10%.
In the largest study yet (n = 1.4 million) the CDC have determined the risk of all complications, whether serious or not, from infant medical circumcision to be 0.5%, and about 10 to 20 times higher for those carried out later (El Bcheraoui et al .2014).
In Africa, the risk of injury is much higher, estimated to be 17.7% clinically and 35.2% for traditional circumcisions. 
As usual Crouch does not tell the whole story. The clinical practitioners in the study had not the training or equipment to conduct circumcisions safely. Great efforts have since been put into developing safe methods and providing resources so it is misleading to base a complaint on one study of one district in one country which identified issues that have since been addressed. And to compare medical circumcision with traditional circumcision is absurd.
As the AAP conceded in its 2012 policy statement, the true extent of the risks associated with circumcision is unknown.
See El Bcheraoui et al. 2014.
Circumcision Diminishes Every Man’s Sex Life. Circumcision removes one-half of the penile covering, the size of a postcard in an adult.
There is such variation in penile sizes and proportions it is not possible to give a “one size fits all” figure. Intactivists also count both inner and outer surfaces to make it seem larger.
The foreskin is replete with blood vessels and specialized nerves such as stretch receptors. The foreskin is, and circumcision removes, the most sensitive part of the penis. 
Here Crouch cites another dubious work by intactivists. Aside from the round of criticism (Waskett & Morris 2007), counter-criticism (Young 2007) and further criticism (Morris & Krieger 2013) it attracted, the study looked only at one kind of sensitivity – fine touch. But is this the right kind of sensitivity? Fine touch comes from nerve endings called Meissner’s corpuscles which are present in the foreskin, but even more so in the fingertips (Bhat et al. 2008), and we do not consider fingertips erogenous. Pleasurable erotic sensations come from genital corpuscles which are concentrated around the glans, not the foreskin. So the whole study may be a red herring. It is certainly cherry-picked. Other studies find no difference between the circumcised and the uncircumcised. Like Bleustein et al. (2005) who tested a broader range of sensation types (vibration, pressure, spatial perception and temperature) and found no difference between circumcised and uncircumcised. For every study the intactivists cherry-pick to suit their agenda, another can be found that contradicts it. Tellingly, the only meta-analysis to date, on the ten best studies, found that circumcision makes no difference to male sexual function (Tian et al. 2013). An independent review found the same (Morris & Krieger 2013).
African men will be outraged to learn that circumcision not only has failed to protect them from HIV but has forever diminished their sex lives. Female partners of circumcised men also report reduced sexual satisfaction. 
More cherry-picking. There are studies which found that women report a preference for circumcised partners (e.g. Williamson & Williamson 1988) including a randomised controlled trial (table 2 in Krieger et al. 2008).
Africans Are Being Misinformed, Coerced, and Exploited. African men are not being informed of the truth, that circumcision is painful, risky, and harmful; that in itself it gives little to no protection from HIV, and the surgery itself may infect them with HIV. Serious ethical violations are occurring as usually poor Africans are being offered valuable incentives to volunteer such as free medical care.  Boys as young as fifteen years old are being coerced, such as being offered team uniforms and equipment in exchange for being circumcised.
As usual the reference Crouch cites here (no. 16) is one that was comprehensively debunked, as mentioned earlier.
Call For Action. Your Foundation’s mass circumcision program violates science, medical ethics, and the law. Your Foundation should immediately terminate its misplaced support of the African mass circumcision program. Your Foundation should also immediately initiate a comprehensive investigation into the program led by unbiased experts, ethicists, and of course Africans. Otherwise, the legacy of the Gates Foundation, and inevitably your personal legacy, will be that you and your Foundation funded one of the most harmful medical programs in human history, and also that you and your Foundation failed to stop it after being informed that it had failed.
Harry Crouch’s letter violates truth and reason. Although there is plenty of evidence in it for scholarly incompetence (such as the garbled referencing), the ignoring of detailed debunkings and the use of discredited studies, are so systematic from start to finish that it is difficult to see this as being due to mere ineptitude. The selectivity and use of fringe sources like Gisselquist add to the charge that Crouch’s open letter is agenda-driven anti-medical pseudoscience. I urge the Foundation to disregard it, and any future pressure from anti-circumcision groups, and to continue to back scientifically proven interventions, including circumcision, in the face of a deadly epidemic that has killed millions.
References in the NCFM (Harry Crouch) letter.
1 G.W. Dowsett and M. Couch, “Male circumcision and HIV prevention: is there really enough of the right kind of evidence?,” Reproductive Health Matters, 15, no. 29 (2007): 33-44; L.W. Green, R.G. McAllister, K.W. Peterson, and J.W. Travis, “Male circumcision is not the HIV ‘vaccine’ we have been waiting for!,” Future HIV Therapy, 2, no. 3 (2008):193-99; D. Sidler, J. Smith, and H. Rode, “Neonatal circumcision does not reduce HIV/AIDS infection rates,”. South African Medical Journal, 98, no. 10 (2008):762-6.
2 Robert S. Van Howe and Michelle R. Storms, “How the circumcision solution in Africa will increase HIV infections”, Journal of Public Health in Africa, Vol. 2, No. 1 (2011) (http://www.publichealthinafrica.org/index.php/jphia/article/view/jphia.2011.e4/html_9 ); Boyle & Hill, supra n.1; D.D. Brewer, J.J. Potterat, and S. Brody, “Male circumcision and HIV prevention,” Lancet, 369 (2007): 1597; L.W. Green, J.W. Travis, R.G. McAllister et al., “Male circumcision and HIV prevention: insufficient evidence and neglected external validity,” American Journal of Preventive Health, 39 (2010): 479-82.
4 F.E. Makumbi, R.H. Gray, M. Wawer et al., “Male post-coital penile cleansing and the risk of HIV acquisition in rural Rakai district, Uganda,” abstract from presentation at Fourth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, Sydney, 2007, available at http://www.iasociety.org/Default.aspx?pageId=11&abstractId=200705536.
5 F.E. Makumbi, R.H. Gray, M. Wawer et al., “Male post-coital penile cleansing and the risk of HIV acquisition in rural Rakai district, Uganda,” abstract from presentation at Fourth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, Sydney, 2007, available at: http://www.iasociety.org/Default.aspx?pageId=11&abstractId=200705536.
8 M. Garenne, A. Giamland, and C. Perrey, “Male Circumcision and HIV Control in Africa: Questioning Scientific Evidence and the Decision-making Process,” in T. Giles-Vernick and J.L.A. Webb Jr., eds., Global Health in Africa: Historical Perspectives on Disease Control (Athens, Ohio: Ohio University Press, 2013): 185-210, at 190 (“Garenne Male Circumcision and HIV Control”). (http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.0030078 ).
9 Van Howe & Storms, supra n.12.
10 Gisselquist D, Potterat JJ. Heterosexual transmission of HIV in Africa: an empiric estimate. Int J STD AIDS 2003;14:162–73 (www.rsm.ac.uk/new/std162stats.pdf ).
11 Van Howe & Storms, supra n.12.
12 Van Howe RS. “Circumcision and HIV infection: review of the literature and meta-analysis”. Int J STD AIDS 1999;10:8–16.
13 Bailey RC, Egesah O, Rosenberg S. “Male circumcision for HIV prevention: a prospective study of complications in clinical and traditional settings in Bungoma, Kenya”. Bull World Health Organ 2008; 86: 669-77.
14 Sorrells et al. “Fine-touch pressure thresholds in the adult penis”, BJU Int. 2007 Apr;99(4):864-9 at http://www.ncbi.nlm.nih.gov/pubmed/17378847 .
15 Frisch et al, “Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark” (2011), at http://ije.oxfordjournals.org/content/early/2011/06/13/ije.dyr104.full ; and “Effects of male circumcision on female arousal and orgasm”, New Zealand Medical Journal, Vol. 116, No. 1181: 595-96, September 12, 2003.
16 Boyle & Hill, supra n.1.
References for the annotations
Auvert, B., Taljaard, D., Dino Rech, D., Lissouba, P., Singh, B., Bouscaillou, J., Peytavin, G., Mahiane, S.G., Sitta1, R., Puren, A., Lewis, D. (2013) Association of the ANRS-12126 Male Circumcision Project with HIV Levels among Men in a South African Township: Evaluation of Effectiveness using Cross-sectional Surveys. PLoS Med., 10(9), e1001509.
Banerjee, J., Klausner, J.D., Halperin, D.T., Wamai, R., Schoen, E.J., Moses, S., Morris, B.J., Bailis, S.A., Venter, F., Martinson, N., Coates, T.J., Gray, G., Bowa, K. (2011) Circumcision Denialism Unfounded and Unscientific. Am. J. Prev. Med., 40(3), e11-e12
Bhat, G.M., Bhat, M.A., Kour, K., Shah, B.A. (2008) Density and Structural Variations of Meissner’s Corpuscle at Different Sites in Human Glabrous Skin. J. Anat. Soc. India., 57(1), 30-3.
Bleustein, C.B, Fogarty, J.D., Eckholdt, H., Arezzo, J.C., Melman, A. (2005) Effect of neonatal circumcision on penile neurologic sensation. Urology, 65(4), 774-7.
Borenstein, M., Hedges, L., Higgins, J.P.T., Rothstein, H.R. (2009) Introduction to Meta-Analysis, John Wiley and Sons, West Sussex.
Brewer, D.D., Potterat, J.J., Roberts, J.M., Brody, S. (2007) Male and Female Circumcision Associated With Prevalent HIV Infection in Virgins and Adolescents in Kenya, Lesotho, and Tanzania. Ann. Epidemiol., 17(3), 217-26.
Castellsagué, X., Albero, G., Cleries, R., Bosch, F.X. (2007) HPV and circumcision: A biased, inaccurate and misleading meta-analysis, J Infect., 55, 91-3.
El Bcheraoui, C.E., Zhang, X., Cooper, C.S., Rose, C.E., Kilmarx, P.H., Chen, R.T. (2014) Rates of Adverse Events Associated With Male Circumcision in US Medical Settings, 2001 to 2010. JAMA Pediatrics, E1-E10.
Garenne M (2006) Male Circumcision and HIV Control in Africa. PLoS Med., 3(1), e78-e79.
Halperin, D.T. & 47 others (2008) Male circumcision is an efficacious, lasting and cost-effective strategy for combating HIV in high-prevalence AIDS epidemics. Future HIV Therapy, 2(5), 399-405.
Jean, K., Lissouba, P., Taljaard, D., Taljaard, R., Singh, B., Bouscaillou, J., Peytavin, G., R. Sitta, R., Mahiane, S.G., D. Lewis, D., A. Puren, A., B. Auvert, B. (2014) “HIV incidence among women is associated with their partners’ circumcision status in the township Orange Farm (South Africa) where the male circumcision roll-out is ongoing (ANRS-12126)”. 20th International AIDS Conference; Abstract FRAE0105LB.
Krieger, J.N., Mehta, S.D., Bailey, R.C., Agot, K., Ndinya-Achola, J.O., Parker, C., Moses, S. (2008) Adult male circumcision: Effects on sexual function and sexual satisfaction in Kisumu, Kenya. J Sex Med., 5, 2610-2622.
L’Engle, K., Lanham, M., Loolpatit, M., Oguma, I. (2014) Understanding partial protection and HIV risk and behavior following voluntary medical male circumcision rollout in Kenya. Health Education Research. 29(1), 122-130.
Mattson, C.L., Campbell, R.T., Bailey, R.C., Agot, K., Ndinya-Achola, J.O., Moses, S. (2008) Risk Compensation Is Not Associated with Male Circumcision in Kisumu, Kenya: A Multi-Faceted Assessment of Men Enrolled in a Randomized Controlled Trial. PLoS One, 3(6), e2443.
Morris, B.J., Bailey, R.C., Klausner, J.D., Leibowitz, A., Wamai, R.G., Waskett, J.H., Banerjee, J., Halperin, D.T., Zoloth, L., Weiss, H.A., and Hankins, C.A. (2012) A critical evaluation of arguments opposing male circumcision for HIV prevention in developed countries. AIDS Care. 24(12), 1565-1575.
Morris, B.J., Hankins, C.A., Tobian, A.A.R., Krieger, J.N., Klausner, J.D. (2014) Does Male Circumcision Protect against Sexually Transmitted Infections? Arguments and Meta-Analyses to the Contrary Fail to Withstand Scrutiny. ISRN Urology, Article ID 684706.
Morris, B.J. and Krieger, J.N. (2013) Does Male Circumcision Affect Sexual Function, Sensitivity, or Satisfaction? – A Systematic Review. J. Sex. Med., 10(11), 2644-57.
Morris, B.J., Waskett, J.H., Gray, R.H., Halperin, D.T., Wamai, R., Auvert, B., Klausner, J.D. (2011) Exposé of misleading claims that male circumcision will increase HIV infections in Africa. J. Public Health in Africa, 2(e28), 117-122.
Ndebele, P., Ruzario,S., Gutsire-Zinyama, R. (2013) Point of View: Interpreting and dismissing the relevance of the “wait and wipe” finding from the circumcision studies conducted in Africa. Malawi Medical Journal, 25(4), 113-115.
Riess, T.H., Achieng’, M.M., Otieno, S., Ndinya-Achola, J.O., C. Bailey, R.C. (2010) ‘‘When I Was Circumcised I Was Taught Certain Things’’: Risk Compensation and Protective Sexual Behavior among Circumcised Men in Kisumu, Kenya. PLoS One, 5(8), e12366.
Schmid, G.P., Buvé, A., Mugyenyi, P., Garnett, G.P, Hayes, R.J., Williams, B.G., Calleja, J.G., De Cock, K.M., Whitworth, J.A., Kapiga, S.H., Ghys, P.D., Hankins, C., Zaba, B., Heimer, R., Boerma, J.T. (2004) Transmission of HIV-1 infection in sub-Saharan Africa and effect of elimination of unsafe injections. Lancet, 363, 482-8.
Tian, Y., Liu, W., Wang, J.Z., Wazir, R., Yue, X. & Wang, K.J. 2013. Effects of circumcision on male sexual functions: a systematic review and meta-analysis. Asian J. Androl., 15, 662-6.
Wamai, R.G., Morris, B.J., Waskett, J.H., Green, E.C., Banerjee, J., Bailey, R.C., Klausner, J.D., Sokal, D.C. & Hankins, C.A. 2012. Criticisms of African trials fail to withstand scrutiny: Male circumcision does prevent HIV infection. J Law Med., 20(1), 93-123.
Waskett, J.H., Morris, B.J. (2007) Fine-touch pressure thresholds in the adult penis. BJU Int., 99(6), 1551-2.
Wawer, M.J., Gray, R.H., Serwadda, D., Kigozi, G., Nalugoda, F., Quinn, T.C. (2011) Male Circumcision As a Component of Human Immunodeficiency Virus Prevention. Am. J. Prev. Med. 40(3), e7-e8.
Wawer M.J., Makumbi F., Kigozi G., et al. (2009) Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet, 374, 229–237.
Westercamp, N., Agot, K., Jaoko, W., Bailey, R.C. (2014) Risk Compensation Following Male Circumcision: Results from a Two-Year Prospective Cohort Study of Recently Circumcised and Uncircumcised Men in Nyanza Province, Kenya. AIDS Behav. Epub ahead of print.
Williamson, M.L., Williamson, P.S. (1988) Women’s preferences for penile circumcision in sexual partners. J Sex Educ Ther., 14(2), 8-12.
Young, H. (2007) Fine-touch pressure thresholds in the adult penis. BJU Int., 100(3), 699.
Why not remove the breast buds (or appendix, etc.)?
A favourite argument amongst intactivists is to compare circumcision with the removal of some other body part. They then ask why we don’t prophylactically remove those other body parts. In every case the argument is absurd, being based on the fallacy of false equivalence (http://circfacts.org/sloppy-logic/#slog13 ). It is likely that circumcision is unique, there being no other prophylactic surgery that would win both a risk/benefit and a cost/benefit analysis, although in certain limited cases some possibly do, as with removal of molars if there is insufficient space, or breasts when the woman has a gene that makes it probable she will develop breast cancer. But uniqueness is not an argument against a procedure.
Even skeptics and debunkers, who ought to know better, are guilty. A recent (2017), and particularly spectacular, example is a video on circumcision by UK “skeptic” Stephen Woodford, of the YouTube channel “Rationality Rules”. (https://www.youtube.com/watch?v=3z5OESt3TCg ). In his case he picked breasts and the appendix as his examples. Evidently rationality no longer rules when Mr Woodford takes on circumcision.
This argument is so common it merits a detailed debunking. Happily this has been done admirably already. One such, by a physician, may be seen here: https://circumscience.wordpress.com/2015/03/12/prophylactic-mastectomy-should-never-be-compared-to-routine-infant-circumcision/ The author eloquently demolishes the asinine comparison with breast bud removal.
Another, by Melanie Lindwall Schaab, originally posted on the “Elephant in the Hospital” Facebook page (https://www.facebook.com/groups/elephantinthehospital/ dated 3 August 2016) is reproduced here with permission. It explores a wider range of possible prophylactic surgeries, and shows just how asinine the comparison with circumcision is. Enjoy.
Why Not the Breast Buds?
By Melanie Lindwall Schaab
Intactivists often draw comparisons between removing the foreskin and removing other organs in an attempt to demonstrate how ridiculous it is to think that prophylactically removing the foreskin of a newborn is beneficial. “If you’re going to remove the foreskin, why not the appendix? Or your daughter’s breast buds?” Although the argument is likely facetious, I decided to take it at face value and respond intelligently to their question. The organs usually brought up for comparison are the wisdom teeth, tonsils, appendix, and breast buds.
|Type of Anesthesia||Medical Indication||Complication Rate||Age of Lowest Risk||Cost|
|Wisdom Teeth||Local||12-80%||2.6-30.9%||Adolescent /Adult||$2,000|
Anesthesia. Local anesthetic is used in newborn circumcisions. Child circumcisions typically use general anesthetic. Adult circumcisions may use either general or local, and so can be expected to cost less than child circumcisions but far more than newborn circumcisions.
Medical Indication. Circumcision is medically indicated in roughly 10% of males not circumcised at birth. However, approximately half (50%) of males will experience complications related to retaining their foreskins [Morris, Bailis, & Wiswell, 2014]. In this way, the foreskin is different from all the other organs suggested here because it may cause problems without the problems being so severe as to warrant removal. In other words, let’s say you don’t have him circumcised as a newborn. There’s a 2.2% chance he’ll end up with a UTI in the first year of life, and the average cost of treating a UTI in a male infant is $1,111 [Schoen, Colby, & Ray, 2000]. That single UTI alone costs about four times more than his newborn circumcision would have and involves more pain and medication for treatment of the problem than his newborn circumcision would have warranted. Nevertheless, getting him circumcised at that age (past the newborn stage) would cost so much that it might result in net financial loss and the complications associated with a later circumcision are much higher and may pose more danger than the complications associated with a single UTI. He may end up with more complications related to foreskin retention, or he may not. Furthermore, especially if he lives in a country where newborn circumcision is rare, getting him circumcised poses a serious risk of causing emotional problems down the road due to feeling like the “odd man out” or “abnormal” or “damaged.” Therefore, most foreskin problems are treated the less expensive route, which involves throwing drugs at the patient rather than removing the offending organ. By contrast, appendicitis, symptomatic wisdom teeth, tonsillitis, and breast cancer are all by far most often treated with removal of the offending organ. Tonsillitis is the only one that may often be treated without surgery, but nevertheless, the vast majority of tonsillitis cases are treated with surgery, unlike foreskin problems, the majority of which are not treated with circumcision. So that’s why I put both 10% (the number who need a circumcision) and 50% (the number who have foreskin-related complications).
Complication Rate. Complications occur in about 0.2-0.6% of prophylactic newborn circumcisions [Kacker et al, 2012]. Post-newborn circumcisions (infant, child, adolescent, adult) pose over 10 times higher risk with a complication rate of roughly 6% [Weiss, 2010]. Benefits of prophylactic newborn circumcision outweigh the risks at least 100 to 1 [Morris, Bailis, & Wiswell, 2014]
Age at Lowest Risk. Newborns experience the lowest incidence of complications. The complication rate is 10-20 times higher in adults as compared to newborns.
Cost. Circumcisions cost on average $291 in the U.S. [Kacker et al, 2012]. Circumcision affects not just the risk of later medically-necessary circumcision, but of a wide range of other problems in males and their female partners, including genitourinary infections, sexually-transmitted infections, cancers, and structural problems. When all of these are considered, prophylactic newborn circumcision results in significant cost savings, even if you were to take the money you would have spent on the circumcision and put it in an investment account with 3% interest. [Ganiats et al, 1991; Lawler, Bisonni, & Holtgrave, 1991; Colby et al, 2001; Gray, 2004; Schoen, Colby, & To, 2006; Morris, Castellsague, & Bailis, 2006; Kacker et al, 2012]
Conclusion. Although the total number of risks and benefits are small, the ratio strongly favors circumcision, specifically newborn circumcision, and prophylactic newborn circumcision results in significant savings on health expenses across the lifespan.
Anesthesia. Prophylactic removal of the wisdom teeth is typically performed under local anesthesia. Similarly, prophylactic newborn circumcision is typically performed under local anesthesia.
Medical Indication. Experts estimate that as many as 80% of people whose wisdom teeth are not prophylactically removed will have complications later, most requiring removal; nevertheless, many are now calling for prophylactic wisdom tooth extraction to be ended [Rabin, 2011]. In this way, it’s similar to the foreskin because at least half of males whose foreskins are not prophylactically removed will have complications later, a sizeable minority of which require removal; and in spite of this, many are now calling for newborn circumcision to be ended.
However, unlike circumcision, the exact statistics of wisdom tooth removal—specifically, how frequently it’s medically indicated—are scarce, and the actual number is probably far lower, around 25%, with one study estimating it to be medically necessary in only 12% of cases [Rabin, 2011]. In this case, it’s again similar to the foreskin, removal of which is medically necessary in about 10% of males.
However, it’s also dissimilar to the foreskin because wisdom teeth that cause no problems are not removed while wisdom teeth that cause any symptoms whatsoever are removed [Rabin, 2011]—in other words, the total complication rate from wisdom teeth retention is as low as 12%. However, the foreskin is most often not removed if it causes minor problems and only removed if it causes serious problems. Since serious problems may occur in about 10% and minor problems in about 50%, complications of foreskin retention are likely far higher than complications of wisdom teeth retention.
Impacted wisdom teeth can be asymptomatic initially, but later result in long-term damage [Brauer et al., 2013]. In this way, it’s similar to the foreskin, which may not have any symptoms initially but ultimately result in a condition requiring circumcision or more radical surgeries as treatment, such as lichen sclerosis or penile cancer.
Complication Rate. One area where there is a glaring difference between wisdom teeth removal and circumcision is in the risks of the surgery. While the overall complication rate from newborn circumcisions hangs around 0.2-0.6% and the serious complication rate is about 0.01%, the overall complication rate from wisdom teeth extraction is 2.6-30.9% and the serious complication rate is roughly 1% [Brauer et al, 2013]. This means the overall complication rate of wisdom tooth extraction is roughly 42 times higher and the serious complication rate is 100 times higher than with circumcision.
Age at Lowest Risk. Another significant difference between wisdom teeth extraction and circumcision is that it is not necessarily better when performed at a younger age. Circumcision of older children and adults poses more than a 10 times higher complication incidence as compared to circumcision of newborns. In contrast, wisdom teeth removal can only be performed in older children at the youngest because they don’t exist in young children or infants.
Cost. The cost of prophylactically removing all four wisdom teeth ranges $1,000 to $3,000 depending on region and how complicated the procedure is [CostHelper, 2015]. This is almost 10 times higher than the cost of newborn circumcision. Because wisdom tooth problems are exclusively treated with surgical removal, a financial cost-benefit analysis is a simple matter of comparing the cost to remove all people’s wisdom teeth versus the savings from removing wisdom teeth in people who would have needed it anyway. If 25% of people require wisdom tooth removal and it costs $2,000 per person, prophylactically removing all wisdom teeth would pose a net cost of $500 per person. In contrast, newborn circumcision results in significant cost savings.
Conclusion. Thus, because the benefits of prophylactic wisdom tooth extraction are probably low in comparison to the benefits of prophylactic newborn circumcision, and the risks of wisdom tooth extraction are so great in comparison to the risks of circumcision, there is a far narrower risk-benefit ratio. In fact, when looking simply at the complication rates of prophylactic removal versus tooth retention, the risks may outweigh the benefits, but there is little solid data on this. In stark contrast, the benefits of circumcision outweigh the risks at least 100 to 1 based on literally dozens of studies on the topic. Furthermore, prophylactic wisdom tooth removal would result in significant financial loss, while newborn circumcision results in significant cost savings.
Anesthesia. Tonsils are removed under general anesthesia. This is the opposite of newborn circumcision.
Medical Indication. The reasons for tonsillectomies have shifted from predominately due to infection in the 1970s to predominately due to upper airway obstruction in the 2000s [Erickson et al, 2009]. This is due in part to changes in treatment, where physicians prefer to administer antibiotics repeatedly rather than remove the offending organ (in part because the recurrent tonsillitis may resolve over time), to improved ability to diagnose airway obstruction causing obstructive sleep apnea (OSA), and to greater understanding of the health, behavioral, and academic risks of OSA [American Academy of Otolaryngology—Head and Neck Surgery, N.d.; Erickson et al, 2009]. Back in 1938 in the U.K., it was thought that 4-6% of children would require tonsillectomy in contrast to a total tonsillectomy incidence of roughly 32% [Glover, 1938]. A recent study of several areas in Italy found that an average of 678 tonsil/adenoid surgeries were performed on children aged 2-9 with an average of 14,726 children aged 2-9 in the population [Fedeli et al, 2008]. This comes out to an incidence of about 4.6%, which agrees with the 1938 British expected incidence of medically-necessary tonsillectomies. This is roughly half of the medically-necessary circumcision rate.
Complication Rate. A recent meta-analysis found that the overall complication rate in children is about 19% [De Luca Canto et al, 2015]. Complications of tonsillectomies in children (19%) is thus roughly 48 times the complication rate of newborn circumcision (0.4%).
Age of Lowest Risk. Moderate to severe complications are much higher in adults (20%) than in children (2-4%) [Seshamani et al, 2014]; thus, the complication rate is roughly 5-10 times higher in adults than in children. In this way, it’s similar to circumcision, where the complication rate is roughly 10-20 times higher in adults than in newborns. However, there’s no apparent benefit to prophylactically removing tonsils in newborns as opposed to older children, as surgery under general anesthetic in newborns is riskier than the same in older children. In this way, it’s different from circumcision, because circumcision of newborns is safer than circumcision of older infants, children, adolescents, or adults.
Cost. The cost of a tonsillectomy ranges $4,000-$7,000 without insurance, averaging $5,500, and it costs about $500 less for children than for adults. An adenoidectomy costs $5,000-8,200, averaging $6,000. A combination tonsillectomy and adenoidectomy costs $10,000-14,000, averaging $11,500 [CostEvaluation, N.d.]. If we consider the approximately 5% of people who will require a tonsillectomy versus the $5,500 it costs per surgery, prophylactically removing 100% of tonsils would constitute a net loss of $275 per person. This net loss might actually be slightly lower because some tonsillitis cases are treated with antibiotics instead of tonsillectomy and the cost of antibiotic treatment (office visit fee, purchase of prescription, sometimes multiple follow-up visits, etc., and tonsillitis has a habit of recurring, meaning that this charge may be doubled or tripled) may be slightly less than the cost of the surgery.
Conclusion. Tonsillectomy is similar to circumcision in that it’s less risky when performed younger, but dissimilar in that it’s riskier in newborns than in children. However, tonsillectomies are required about half as often as circumcision is required, poses 48 times the complication rate as newborn circumcisions, and prophylactic tonsillectomies would pose a net financial loss compared to a net gain with prophylactic newborn circumcision.
Anesthesia. Appendectomies are almost exclusively performed under general anesthesia, which automatically poses much higher risk than the local anesthesia used in circumcisions.
Medical Indication. Lifetime risk of appendectomy is about 12% in males. The incidence is stated to be double in females [BMJ Publishing Group, N.d.], but half of suspected acute appendicitis in females turns out to be something else (e.g., ovarian cyst, ectopic pregnancy, etc.) [Minutolo, 2014]. In this way, it is similar to the foreskin, where about 10% of males will require its removal for medical reasons. However, acute appendicitis is almost exclusively treated with surgery [Craig, N.d.a; Craig, N.d.b], whereas foreskin complications are typically treated without surgery. Thus, while the acute appendicitis rate closely mirrors the appendectomy rate (~12%), the circumcision rate (~10%) is only a fraction of the overall foreskin complication rate (~50%). In other words, the foreskin is far more likely to cause problems than is the appendix, but is just as likely to require removal.
Complication Rate. The complication rate from appendectomies ranges 3% for laparoscopic surgeries to 13% for open surgeries in adults [Minutolo et al, 2014]; thus, open surgery has approximately 4 times higher risk. In children, the risks are significantly higher, at 13% for laparoscopic surgeries to 23% for open surgeries [Paya et al., 2000]; thus, in children, open surgery poses only about double the risk of laparoscopic surgery, but significantly greater risk than the same surgeries in adults. Laparoscopic surgeries occasionally are impossible and must be converted to open surgeries (1.4% in one study of adults [Minutolo et al, 2014] and 4.3% in a study of children [Paya et al, 2000]), so the plan to lower the risk as much as possible by choosing the least risky operation is usually feasible but not entirely predictable [Minutolo et al, 2014]. In contrast, newborn circumcision complications range 0.2-0.6% and adult circumcisions have approximately 10-20 times higher risk. The complication rate from pediatric appendectomies is 33-58 times higher than the complication rate from circumcision. Furthermore, less than 0.01% of newborn circumcisions will require additional surgical correction, which is roughly 150 times lower than the incidence of laparoscopic appendectomies having to be converted to open appendectomies.
Age at Lowest Risk. As discussed above, appendectomies are riskier in children than in adults. Thus, it would be more dangerous as a prophylactic measure performed in infancy than as a prophylactic or treatment measure performed in adolescence or adulthood. The typical age of appendectomies is early teens to late 40s [BMJ Publishing Group, N.d.]. In the hypothetical situation of prophylactically removing appendixes, it would be far safer and more beneficial to wait at least until adolescence; however, with circumcision, it is far safer and more beneficial to perform it in the newborn period.
Cost. Appendectomies cost anywhere from $1,500 to $180,000 in the U.S., averaging about $33,000 [Castillo, 2014]. This contrasts with about $291 for newborn circumcision. Again, acute appendicitis is almost exclusively treated with appendectomy, so we can very accurately estimate the cost of acute appendicitis by simply going with the cost of appendectomies. If 12% of males require appendectomy, and it costs $33,000 on average, prophylactic removal in all males would equal a net cost of $3,960 per patient. In contrast, circumcision saves money.
Conclusion. Appendectomies are required about as frequently as circumcision is required; however, the complication rate from foreskin retention is about 5 times higher than the complication rate from appendix retention. The risks of appendectomies are about 33-58 times higher than the risks of newborn circumcision, and the proportion of appendectomies that require further surgical correction is about 150 times higher than the proportion of newborn circumcisions that require further surgical correction. There is no benefit to performing appendectomies in a younger age (in fact, it would be riskier in a younger patient), and the cost of prophylactic appendectomies would be exorbitant. This contrasts to the benefits of circumcision outweighing the risks at least 100 to 1; greater benefits for circumcision performed at a younger age; and cost savings from circumcision.
When I did the research on these comparisons, I discovered that the breast buds comparison is the absolute most ridiculous argument I’ve ever read. That’s why I saved it for last.
Anesthesia. Mastectomies are performed under general anesthesia.
Medical Indication. The incidence of medically-indicated mastectomy among women in the U.S. is approximately 0.058% [Susan G. Komen, N.d.], compared to a medically-indicated circumcision rate of about 10%. Thus, your son is about 170 times more likely to require circumcision than your daughter is to require a mastectomy.
Prophylactic mastectomy hugely reduces (by about 90%) the risk of breast cancer but does not eliminate it, and removing both breasts when only one has cancer reduces the risk of cancer recurrence by about 95% [Tuttle et al, 2010]. One study of women considered high risk for breast cancer found that those undergoing prophylactic mastectomy had a 0% incidence of breast cancer and those refusing prophylactic mastectomy had a 7% incidence of breast cancer [Domchek, 2010]. Thus, your son is roughly at equal risk of requiring a circumcision later if he isn’t circumcised as a newborn as a high-breast-cancer-risk woman is of developing breast cancer if she doesn’t have a prophylactic mastectomy. Furthermore, breast cancers very rarely appear in women younger than their 40s and are almost completely preventable by prophylactic mastectomy at that age, whereas many of the benefits of circumcision are gone if the procedure is performed at an older age than the newborn period. So it would be more accurate to compare newborn circumcision to prophylactic mastectomies in middle-aged high-risk women.
A rather disgusting but accurate joke I’ve heard is that we feed babies with our breasts, but we don’t feed babies with men’s foreskins. In all seriousness, though, current evidence shows no certain or even likely (only hypothetical) serious detriments to health from the loss of the other organs discussed here, but loss of the breasts can cause serious detriments to both the health of the woman (mastectomy increases the risk of certain cancers, for example) and the health of her baby due to her inability to breastfeed.
Complication Rate. The complication rate from breast cancer surgeries ranges 25% (mastectomy alone) to 56% (mastectomy plus reconstruction) in patients under 65 years of age (median 40.5%); the rate is as high as 69% in patients over 65 [Azvolinsky, 2015]. This compares to an overall complication rate of 0.2-0.6% in newborn circumcisions (median 0.4%). An important note is that intactivists will specifically state “breast buds,” implying that they’re talking only about removing the nipples. However, breast cancers occur not only in the nipples but also (far more commonly) in the surrounding breast tissue and lymph nodes, all of which must be removed, so it cannot be argued that it would be a simpler, less involved surgery in a baby as compared to an adult. Thus, the median mastectomy complication rate is about 101 times higher than the median newborn circumcision complication rate.
Age of Lowest Risk. The risks are lower if the woman is younger when the procedure is performed—namely, if she is middle aged versus if she is elderly, but this is true for all surgeries. All surgeries are riskier in the elderly than in young adults and middle-aged adults, in the same way that most surgeries are riskier in children than in adults, with circumcision being a notable exception. It can be presumed that the risks of prophylactic mastectomy would be greater in children because of the greater risks associated with general anesthesia in children as compared to adults, and the greater difficulty visualizing all of the tissue that must be removed.
Cost. A mastectomy plus reconstruction costs roughly $89,000. Thus, comparing the likelihood that it would have been medically necessary to the cost of the procedure, we have an estimated cost of $5,162 per patient if all girls received prophylactic mastectomies at birth.
Conclusion. This is the most ridiculous of all the comparisons I’ve heard. Your son is 170 times more likely to require circumcision than your daughter is to require a mastectomy; the median complication rate of mastectomies is 101 times higher than the median newborn circumcision complication rate; there is greater risk in children, in stark contrast to circumcision; and it is far from cost effective, unlike circumcision. Removing the breasts prophylactically has also been demonstrated to cause a variety of health problems in the woman and potentially in her children, in contrast to circumcision, which has almost exclusively been demonstrated to prevent health problems in both the male and his female partner(s).
The foreskin is entirely unique in comparison to other organs we might consider prophylactically removing. It is far more likely to cause problems, its removal involves a far lower complication rate, it is the only organ that is safest to remove in newborns, and it is the only organ where prophylactic removal would result in cost savings. Newborn circumcision, the prophylactic removal of the foreskin, simply cannot be logically compared to the prophylactic removal of any other organ.
The simple fact is that circumcision poses benefits that greatly exceed the risks, but both benefits and risks are small in overall number. For instance, uncut boys have about 10 times more UTIs than do cut boys, but only about 2% of cut boys will have a UTI in the first year of life. Nevertheless, given that the benefits outweigh the risks 100 to 1 and that circumcision results in huge cost savings and being uncut is 3 times more likely to be regretted than being circumcised [YouGov, 2015], many parents very logically choose circumcision.
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Weiss, H.A. (2010). “Complications of circumcision in male neonates, infants and children in a systematic review.” BMC Urology, 10:2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2835667/
YouGov (2015). “[Untitled Poll About Circumcision.]” CDN. http://cdn.yougov.com/cumulus_uploads/document/vh7wdbusk2/tabs_OPI_circumcision_20150202%20B.pdf AND http://cdn.yougov.com/cumulus_uploads/document/ugf8jh0ufk/toplines_OPI_circumcision_20150202.pdf
MRI scans and circumcision brain damage?
A common claim is that the pain from infant circumcision causes permanent, and harmful, changes in the baby’s brain. Apart from the fact that local anaesthesia is now normal for infant circumcision, making the argument obsolete, there is simply no credible evidence to support the claim. But a story has circulated on the internet for years claiming that magnetic resonance imaging (MRI) has detected brain damage. Closer investigation, however, reveals the story to be a likely fabrication. And this would not be the first time intactivists have been caught making up stories: witness the “David J. Bernstein” hoax exposed in 2014 (http://circfacts.org/sloppy-logic/#slog22 ). Melanie Lindwall Schaab investigated. Her findings were originally posted on the “Elephant in the Hospital” Facebook page (https://www.facebook.com/groups/elephantinthehospital/ 7 May 2017) which has an excellent archive of articles debunking intactivism. It is reproduced here with permission.
The Lie That Just Won’t Die
By Melanie Lindwall Schaab
Intactivists like to claim that brain scans prove that circumcision causes permanent brain damage. The entirety of the source of this claim is a blog post alleging that a certain individual attempted to conduct a study on the topic but was stonewalled Because Conspiracy. In other words, there’s no actual research for them to cite that found brain damage on brain scans. They just cite this one person claiming on a random blog that this happened.
You would think that alone should be enough for anyone who has read the original blog post (which you can read for yourself here). But damn, this lie just won’t die. So I find myself putting together the responses I’ve given on multiple previous occasions for easier linking and sharing.
The short version is that the study did not happen, but if it had, it would not have proven anything. Here are some of the reasons why
(1) Biased Researchers, Biased Patient, Biased Methods
First off, they explicitly state that the study was performed specifically to prove their hypothesis. They weren’t testing their hypothesis, nor were they trying to prove it wrong. They were trying to prove it right. When researchers are already decided on a given topic, they will generally find the answer they’re looking for. A notable exception was Dr. Wiswell, who was opposed to circumcision and conducted research trying to prove his position right, but instead found that circumcision saves lives and uncut boys are at greater risk of UTIs and hence became pro-circumcision. Of course, intactivists consider him biased, even though he was firmly anti-circumcision before conducting his research.
The author, Dr. Paul Tinari, claims that he was forcefully circumcised by a Catholic priest and a Jewish mohel for masturbating. I call bull on that one. I don’t doubt that, growing up as a Native orphan in a very racist society in mid-1900s Canada, he was abused by his caretakers. However, it’s a common intactivist lie that circumcision was introduced into modern society by Dr. Kellogg in the mid-1800s to prevent masturbation. In reality, no medical text anywhere repeated his theory and the circumcision rates didn’t change after he proposed his theory. It did not have widespread support by any stretch of the definition, so the likelihood that such circumcisions occurred in the mid-1900s is basically 0%. At any rate, he claims that since then, he’s been an anti-circumcision advocate and hopes to have circumcision abolished. Hardly the most unbiased of individuals. Even if he were telling the truth about his personal history, his extreme bias and plainly-stated ulterior motives make him untrustworthy.
Anyway, we find that the “researcher,” Dr. Tinari, states he was firmly anti-circumcision and decided to conduct this study to prove himself right. This is the utmost definition of bias. Then he found a firmly anti-circumcision mom to agree to this unethical research that they next describe. (By the way, what anti-circumcision mom cares so little for her child that she willingly subjects him to something she anticipates will cause serious brain damage?? Does this seriously sound real to you??) So biased researcher, biased patient (in medicine, the parent of a pediatric patient is also considered a patient to some degree), and biased methods.
(2) Irrelevant Technique
They claim they conducted a circumcision without pain medication—no analgesia or anesthesia. This is not how circumcision is typically done today and goes against all major medical organizations’ recommendations. A study on this would be irrelevant because this is not how circumcision is typically done today, and unethical because research ethics requires that no individual be subjected to unnecessary harm. There’s no reason why a newborn should experience circumcision in a medical setting without pain relief.
(3) False Claims Regarding Use of Medical Equipment
Then they claim that they conducted this circumcision in an MRI. He claims that the operator of the MRI machine was a friend of his and agreed to do it after hours. There are SOOOOOOO many problems with this. As someone who has worked closely with the radiation department in a hospital for years, I’m uniquely qualified to explain this.
- A) You don’t get permission from the operator of the machine. Whether he knows the operator or not is irrelevant. (The machine doesn’t belong to the operator and the operator cannot give permission for medical scans!) You get permission from a physician for routine MRIs, and from the ethics committee for anything related to any study whatsoever (see below).
- B) You don’t just borrow an MRI machine’s use. These machines cost millions of dollars. When something in the radiology department breaks, it’s a big deal. Other departments have to get permission to spend a few hundred dollars, but the radiology department spends thousands or millions. You don’t just borrow the use of one of these machines without permission because you “know the operator.” That alone tells me this whole thing is fake.
(4) False Claims Regarding Ethics Permissions
As stated above, you have to get permission from the appropriate ethics committee for anything related to any study whatsoever, which anyone who has ever conducted any research whatsoever will know. Only an incomprehensible moron would think he doesn’t need to talk to the ethics committee about a study. Even Dr. Andrew Wakefield got permission from the ethics committee at his hospital before doing what he would have done with his patients anyway (the colonoscopies and colon samples), and lost his license in part over having not gotten permission from the ethics committee to draw blood. Did you catch that? He lost his license because he didn’t get ethics committee permission to DRAW BLOOD.
Again, I want to emphasize that they didn’t get ethics committee permission prior to allegedly initiating this study. This is utterly ridiculous. No matter how benign your study, even if you’re doing something that you would have done anyway, you still have to get ethics committee permission. Failing to do so can mean jail time. This is serious f***ing stuff. In this case, they had to alter the procedure—putting him in an MRI machine, using plastic tools, forgoing numbing medication, etc.—so it’s literally unbelievable that they would have been so unutterably stupid as to think ethics committee permission would not be necessary.
Seeing what happened to Dr. Wakefield, how can any physician think he would NOT lose his license to practice medicine for drastically altering a surgical procedure and eliminating pain relief for a study without first obtaining ethics committee permission??
Also, they didn’t go to jail for this or at least lose their licenses?
That alone also proves this whole thing is fake.
(6) Pointless Study
Next, they say they followed up for only one month, with no uncircumcised control patient, and are foolish enough to call the alleged changes they allegedly saw on the alleged MRI scan “permanent” changes. Even if they had a control, one patient in each group would not be enough, nor would one month of follow-up. In other words, if they had actually done this, it would have been a pointless study.
(6) False Claims Regarding Societal Bias
I call compete BS on being told that studying the adverse effects of circumcision is considered unethical. Roughly half of Canadian males are circumcised and about one third of newborn boys are circumcised today, meaning the circumcision rate has dropped about 40% from where it was previously. Circumcision isn’t popular, and though the Canada Paediatric Society affirms the benefits of circumcision in its most recent official policy statement (the policy statement in effect at the time of these alleged events did not affirm the benefits of circumcision, so Canada was significantly more anti-circumcision then than it is now), the Canadian government largely doesn’t cover circumcision in its insurance. Needless to say, circumcision is not some sacred cow in Canada. Though if this fictional study had actually taken place, it would certainly have been unethical to perform what is ultimately a useless study (not applicable to modern circumcision due to lack of anesthesia and useless due to no control group, tiny sample size, no long term follow-up, etc.), and illegal to do so without first seeking permission from the ethics committee.
(7) False Claims Regarding Medical Records
Furthermore, they claim their records were deleted.
I say again:
It’s illegal to destroy medical documents. Plain and simple. And are we to believe that in the process of writing up their results for their article, with the images having been seen by numerous people and therefore (by nature of medicine, whether dealing with electronic or physical copies) stored in numerous places, there were no copies anywhere?
Seriously. *heavy sigh*
The fact that the higher ups at the hospital in question did not go to jail for destroying medical records also tells me that this entire story is fake.
In short, it didn’t happen. This story preys on people who have little knowledge of the intricate inner workings of the medical profession. If it had occurred, it wouldn’t have given any indication whatsoever of the effects of circumcision due to the lack of a control group and the tiny sample size.
Brian Earp, Robert Darby, and the not so sceptical “Skeptic”
By Stephen Moreton PhD.
“The Skeptic” is a quarterly magazine published in the U.K. taking a sceptical look at all manner of pseudoscience. Not to be confused with its Australian namesake, the last paper issue (Vol. 26, no. 3) was in 2016. It is now entirely on-line: https://www.skeptic.org.uk/
In spring 2013 it carried an article by English “skeptic” Dr Marianne Baker (PhD in cancer research), a self-confessed intactivist. Replete with the usual fallacies, and a citations list full of references to intactivist works and websites, it was shot down in a letter in the following issue by yours’ truly. Coincidentally, at about the same time, I had written an article exposing the intactivist movement for the pernicious pseudoscientific cult it is. So I submitted it to the Skeptic editor, Deborah Hyde. This article, it should be noted, was pointedly neutral about circumcision outside of high-HIV settings, instead focussing on debunking intactivism.
Unbeknownst to me, Prof. Brian Morris, of the University of Sydney, submitted his own response to Dr Baker’s article, in which he presented a science-based case in favour of circumcision. The editor opted for his, instead of mine, and it appeared in the Autumn 2013 issue (Vol. 24, no. 4). This paved the way for a “rebuttal” by leading intactivists Brian Earp and Robert Darby in the Spring 2015 issue (Vol. 25 no. 3). Theirs’ was an appalling piece of misleading pseudoscientific nonsense that cherry-picked and misrepresented its way through the literature, made ad hominem attacks on Prof. Morris, and was deafeningly silent on African HIV.
Naturally I wrote a rebuttal. I spoke to Deborah Hyde in person at a skeptics conference later that year (QED, Manchester). In the course of our conversation she admitted that Earp & Darby’s piece had not received any form of peer-review at all. Quelle surprise. She also said she would not use my rebuttal as she thought the subject had been aired enough already (although I gave her it anyway so she could not claim ignorance of Earp & Darby’s errors), but she said she would accept a letter of about 300 words. So I wrote her one. It never appeared. Subsequent emails enquiring about it were ignored. To compound matters, Earp & Darby’s piece was put on-line, a privilege granted to very few “Skeptic” articles. Consequently this gave the article vastly greater coverage and led to it being cited extensively by intactivists (including Earp). When I spoke to her in 2015 Hyde offered to link to my rebuttal should I post it on-line. At the time circfacts.org did not exist, but it does now. So I reminded her in March 2018 when this post was made. Unusually I got a (brief) reply – in which she declined.
The trio of articles are now listed on-line here: https://www.skeptic.org.uk/society-culture/the-first-cut/ Tellingly, my letter rebutting the first is not even mentioned, and the link for Prof. Morris’ article does not work, so readers only get to see the intactivist articles, not the rebuttals, and will have no inkling that rebuttals (other than Morris’) were even written, the editor having now twice gone back on her word about allowing some form of reply.
As Earp & Darby’s article still gets cited from time to time, and for the benefit of real skeptics seeking both sides of the debate, my rebuttal, refused by Deborah Hyde, is reproduced below. So readers can see for themselves that the editor of a popular “skeptic” magazine fell for intactivist propaganda and polluted an otherwise fine publication with pseudoscience.
Intactivism is not skepticism
A response to the article by Earp & Darby in “The Skeptic”, Spring 2015.
Predictably Earp & Darby (E&D) open their critique of Prof Morris’ circumcision article with a lengthy ad hominem against him, continuing this theme throughout their polemic. This style of attack is popular amongst intactivists, as their evidence is weak.
That Morris self-cites shows he has written copiously on the subject, but says nothing about the quality of his writings. Having read many I can say they are not identical, but if there are recurring themes it is unsurprising. Intactivists endlessly trot out the same tired old canards, so the answers are the same too.
E&D overlook that most of Morris’ works are co-authored by others, often researchers in the field from respected institutions, and published in high-impact peer-reviewed journals. They try to downplay his credentials, but Morris is a professor emeritus of medical science, familiar with medical literature, terminology and statistics, with >350 publications (70 on circumcision). Darby’s PhD is in history, and Earp’s scientific background (cognitive science & psychology) is as irrelevant as mine (chemistry & geology). People who live in glass-houses …
As for Morris’ pro-circumcision stance, and criticisms thereof, E&D are both prominent intactivists whose own writings on the topic have been heavily criticised [1, 2, 3]. Pot, kettle, black. And how do they know Morris’ letters to journal editors were not peer-reviewed? Mine to the Journal of Medical Ethics were, unlike their “Skeptic” article.
Their account of the AAP is misleading. The 38 “authorities” who responded were rebutted by the AAP . In fact there has been a fierce debate since the AAP policy change. If you have the stamina read the exchange in the Journal of Medical Ethics and see how intactivists’ initial attempts to use technical arguments were refuted by Morris and others . So they switched to personal attacks on Morris whose response showed that even these lacked merit (search on “circumcision” in the archived eLetters for this and more).
There is little evidence that the exposed glans becomes desensitised. At least E&D acknowledge in the footnotes that their source for this  was subject to a round of criticism and response. The main criticism, that the sample was biased by self-selection, stands. The lead author, Bronselaer, conceded this, and mentioned that the circumcision rate in Belgium is 15 %, as opposed to his sample’s 22.6 %. E&D ignore a further critique  which pointed out that 12.1 % of Bronselaer’s sample were gay. Clearly his is not a representative sample.
E&D say 11 babies were admitted to a Birmingham hospital for serious complications following circumcision in 2011. But they don’t say how many thousands of others were circumcised in the same period without mishap, or how these 11 were circumcised. Were they by non-medical providers in ethnic communities? Without this extra data the figure is useless. The consistently low figures (0 – 2) for previous years then an upsurge to 6 in 2010 and 11 in 2011 suggests there is something else going on here, apart from the chutzpah of E&D who cherry-pick the highest figure for a ten year period (the average is 2.4) after accusing Morris of drawing “on the highest possible extremes of available morbidity statistics”.
Their tendency to pick extremes, whilst accusing Morris of this, is also manifest in their quote from the Royal Dutch Medical Association (KNMG), the most anti-circumcision of all the western medical organisations. Although its statement was not accompanied by an extensive review of the current literature, unlike the AAP’s, and its principle mover and co-author (Gert van Dijk), like Earp, is not a medical scientist, but a philosopher and ethicist with a history of hobnobbing with intactivists. Note that none of the bodies E&D cite, not even the intactivist-influenced KNMG, claim circumcision detracts from pleasure and function, or oppose it in high-HIV countries. Intactivists do.
E&D omit the CDC’s finding of <0.5 % for all complications, serious or not, from infant medical circumcision . This is the largest study yet (n = 1.4 million) and additionally found the complication rate was 10 to 20 times higher for circumcisions after infancy. It also refutes the KNMG claim that various complications are “particularly common”. Truly, the KNMG’s statement is not evidence-based. The CDC now agrees with the AAP that the benefits of medical infant circumcision outweigh the risks, even in the USA, and it should be made available. By January this year it had attracted 3276 comments in a public consultation, nearly all of them hostile, thanks to a concerted social media campaign by intactivists.
E&D’s figure for pathological phimosis, overlooks physiological phimosis, which is very common. They claim that phimosis can be cured by stretching, without acknowledging the wildly variable reported failure rates (5 – 33 %) and lack of follow-up to adulthood. Their claims about UTIs overlook that these often occur later in girls, when the highest risk of renal damage has passed, and circumcision provides protection for adults too. They misrepresent a Cochrane review on UTIs that looked only for RCTs and found none, but excluded observational studies, of which there are over 20, and two meta-analyses, all finding a protective effect. So it is disingenuous to assert that it “found no reliable evidence”, it just found no RCTs (in fact it missed one, and it too found a protective effect).
E&D claim that penile cancer “is so rare in Western countries that reliable statistics cannot be generated”. Yet the NHS report on their website about 550 diagnoses a year in the U.K. But then the source E&D cite does not say that “reliable statistics cannot be generated”, it just says they are harder to generate. So E&D misrepresent their source – again.
In developed countries roughly one in 1,000 to 2,000 uncircumcised men will suffer this dreadful disease in their lifetimes. In some developing countries it is one of the most common cancers in men, and is increasingly turning up in young men. Childhood, but not adult, circumcision is highly protective against it .
What E&D exclude is as revealing as what they include but misrepresent. Truly astonishing is the lack of discussion of African HIV. By this summer ten million men will have been circumcised with the backing of the WHO, CDC, PEPFAR, UNAIDS and local medical/health organisations, and it is being extended to children and infants. Yet the greatest circumcision promotion ever goes without mention by E&D. Perhaps Earp is still smarting from the thrashing he got on the quackdown blog when he trespassed into this area in 2012 . It also undermines E&D’s claim that men who have retained their foreskins will not want to give them up. Seeing your peers dying from AIDS has a salutary effect, it seems. So does simply being educated about the benefits in a non-circumcising, low-HIV country like China. Just released is a study in which 45.5 % of male patients at three Chinese STI clinics were willing to be circumcised at their own expense for protection against STIs .
The protection is only partial, but is far better established, with RCTs and meta-analyses in support, than E&D imply by cherry-picking a couple of contradictory studies, and going on about how uncertain it all is. Curiously, after circumcision, 52 % of those Chinese men had improved sexual function. I wonder how many more would have taken up the procedure had it been free, and without the other barriers that deter many men (identified in studies relating to the African program). Barriers like fear of pain or complications, embarrassment, time off work, and a 6 week period of sexual abstinence during healing. None of which apply to infants. E&D may be surprised at how many men, once given accurate information (not intactivist propaganda) are positive about circumcision, but scared off by the aforementioned barriers.
I could continue in similar vein for most of E&D’s assertions but have not the space. E&D’s polemic is ad hominem, selective with the literature, misleading with what it does cite, and its omission of the African circumcision program for HIV-prevention extraordinary. Giving their article so much coverage does a grave disservice to skepticism, gives intactivism a credibility it does not deserve, and plays into the hands of intactivists who have already been citing it in their writings, including Earp, despite his disapproval of self-citation.
Intactivist nonsense is penetrating the skeptical community and being parroted uncritically by people who should know better. Circumcision is often a religious custom and we skeptics tend to be atheistic. So there is a tendency for us to dismiss it as just another stupid religious practice. In short, intactivism triggers our confirmation bias, so we tend not to look further. But we must, since the truth is not as simple as intactivists would have us believe. Perhaps we should exercise a little humility and acknowledge that maybe, in all their centuries of doing wacky things, some religions might have hit upon something important.
If there are any points readers should take away from this debate they are:
- If you are circumcised, relax, you are not missing much. Intactivists greatly exaggerate the supposed merits of the foreskin, but it is hype and speculation aimed at making circumcised men angry, and parents guilty about circumcising their sons.
- Circumcision has medical benefits. One can debate whether they justify the procedure as a prophylaxis, and the answer may vary from country to country. But the idea that circumcising a baby will protect him for life is evidence-based, not irrational.
- Beware of intactivism. It is rife with pseudoscience. It damages the psychological well-being of circumcised males, undermines anti-HIV drives in Africa, and hampers rational discourse on circumcision.
E&D are the “respectable” face of intactivism, but there is a dark side. Epidemiologist Elizabeth Pisani commented at the 2014 QED conference about their hate mail, and described them as “loud and mouthy” but that is an understatement. On-line their opponents are vilified, and subjected to appalling abuse. Parents mentioning on Facebook they have circumcised their sons receive torrents of vitriol. Intactivists launch campaigns against academics (like Morris) trying to get them sacked, they picketed the home of the doctor who chaired the AAP’s task force on circumcision and protested Bill Gates over his support for circumcision in Africa. They make death and arson threats against mohels, medics and hospitals. They put their literature into children’s trick-or-treat bags, and some even gloated over the MH17 disaster because six on board were going to a HIV conference with sessions endorsing circumcision. If that isn’t low enough, they cyber-attacked the Catalan Institute of Oncology after it linked HPV and cervical cancer to foreskins, wiping the hard drive of the lead researcher even though he had not recommended circumcision, but merely reported findings intactivists did not like. These are the actions of bullies and zealots, not skeptics. But what do you expect of a movement rife with anti-vaccinationists, HIV/AIDS deniers, and anti-Semites?
Ponder the death toll of AIDS (39 million), and the words of leading U.S. intactivist Matthew Hess. Then any skeptics still sympathetic to intactivism can see the sort of dogmatic, irrational, and utterly callous, people they are associating with: “Even if it could be shown that circumcision provided 100 percent protection against AIDS, I would still be opposed to forcing that onto a child who can’t consent” .
 Geffen, N. (2012) Getting circumcision science right in the media. http://www.quackdown.info/article/getting-circumcision-science-right-media/
 Bailis, S. & Halperin, D. (2006) Review of “A surgical temptation: the demonization of the foreskin and the rise of circumcision in Britain” by R. Darby, BMJ, 332(7534), 183. On-line: http://www.bmj.com/content/332/7534/183
 Jacobs, A.J., Arora, K.S. (2015) Response to Open Peer Commentaries on “Ritual Male Infant Circumcision and Human Rights”, American J. Bioethics, 15(3), W1-W4. On-line (first page only): https://www.tandfonline.com/doi/abs/10.1080/15265161.2015.1000064
 Blank, S., Brady, M., Buerk, E., Carlo, W., Diekema, D., Freedman, A., Maxwell, L., Wegner, S. (2013) Cultural bias and circumcision: the AAP task force on circumcision responds. Paediatrics, 131(4), 801-4. On-line: http://pediatrics.aappublications.org/content/131/4/801.long
 Morris, B.J., Tobian, A.A.R., Hankins, C.A., Klausner, J.D., Banerjee, J., Bailis, S.A., Moses, S., Wiswell, T.A. (2013) Veracity and rhetoric in paediatric medicine: a critique of Svoboda’s and Van Howe’s response to the AAP’s policy on infant male circumcision. J. Med. Ethics. 40(7), 463-70. On-line abstract: http://jme.bmj.com/content/40/7/463.long
 Bronselaer, G. A., Schober, J. M., Meyer‐Bahlburg, H. F., T’sjoen, G., Vlietinck, R., & Hoebeke, P. B. (2013). Male circumcision decreases penile sensitivity as measured in a large cohort. BJU International, 111(5), 820-827. On-line: https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1464-410X.2012.11761.x
 Wang, K., Tian, Y., Wazir, R. (2013) Male circumcision decreases penile sensitivity as measured in a large cohort. BJU International, 112(1), E2-3. On-line: https://onlinelibrary.wiley.com/doi/full/10.1111/bju.12234_4
 Bcheraoui, C.E., Zhang, X., Cooper, C.S., Rose, C.E., Kilmarx, P.H., Chen, R.T. (2014) Rates of adverse events associated with male circumcision in US medical settings, 2001 to 2010. JAMA Pediatrics, E1-E10. On-line: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4578797/
 Larke, N.L., Thomas, S.L., Silva, I.S., Weiss, H.A. (2011) Male circumcision and penile cancer: a systematic review and meta-analysis. Cancer Causes Control, 22, 1097-1110. On-line: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3139859/
 Wang, Z., Feng, T., Lau, J.T. (2016) Needs assessment and theory-based promotion of voluntary medical male circumcision (VMMC) among male sexually transmitted diseases patients (MSTDP) in China. AIDS Behav., 20(11), 2489-502. On-line abstract: https://www.ncbi.nlm.nih.gov/pubmed/25801474