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. Or post items that do not fit well elsewhere.
- 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”
- “Circumcision’s Psychological Damage”? Not so fast Narvaez & O’Connor!
- It’s mutilation!
- Regulation, not prohibition
- Doctors Opposing Circumcision lie about HIV
- Jonathan Meddings and “The Final Cut”: when a rationalist abandons reason.
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)
An article popular amongst intactivists claiming that circumcision is psychologically damaging is debunked in detail here: https://www.circumcisionchoice.com/single-post/Psychological
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%. [3]
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 [4] 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. [5]
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.” [6]
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.” [7]
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. [8]
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.” [9]
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. [10] 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. [13]
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. [14]
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. [15]
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. [16] 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.
Respectfully submitted,
Harry Crouch
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.
3 Id.
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.
6 Id.
7 Id.
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 | |
| Foreskin | Local | 10%/50% | 0.1-0.6% | Newborn | $291 |
| Wisdom Teeth | Local | 12-80% | 2.6-30.9% | Adolescent /Adult | $2,000 |
| Tonsils | General | 5% | 19% | Child | $5,500 |
| Appendix | General | 12% | 13%-23% | Adult | $33,000 |
| Breast Buds | General | 0.058% | 25%-69% | Adult | $89,000 |
FORESKIN
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.
WISDOM TEETH
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.
TONSILS/ADENOIDS
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.
APPENDIX
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.
BREAST BUDS
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).
CONCLUSION
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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Schoen, E.J., Colby, C.J., & To, T.T. (2006). “Cost analysis of neonatal circumcision in a large health maintenance organization.” The Journal of Urology, 175:1111-1115. http://www.ncbi.nlm.nih.gov/pubmed/16469634
Seshamani, M., Vogtmann, E., Gatwood, J., Gibson, T.B., & Scanlon, D. (2014). “Prevalence of complications from adult tonsillectomy and impact on health care expenditures.” Otolaryngology—Head and Neck Surgery, 150(4):574-581. doi: 10.1177/0194599813519972.
Susan G. Komen Foundation (N.d.). “Table 54: Regional differences in rates of mastectomy in the U.S.” Last updated 04 Feb 2015. http://ww5.komen.org/BreastCancer/Table54Geographicvariationinratesofmastectomy.html
Tuttle, T.M., Abbott, A., Arrington, A., & Rueth, N. (2010). “The increasing use of prophylactic mastectomy in the prevention of breast cancer.” Current Oncology Reports, 12(1):16-21. doi: 10.1007/s11912-009-0070-y.
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.
MRI Scans and Circumcision Brain Damage?
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.
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- 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?
Bull.
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:
Bull.
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.
Conclusion
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 was listed on-line here: https://www.skeptic.org.uk/society-culture/the-first-cut/ (link broken as of February 2021). Tellingly, my letter rebutting the first was not even mentioned, and the link for Prof. Morris’ article did not work, so readers only got to see the intactivist articles, not the rebuttals, and will have had 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 [4]. 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 [5]. 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 [6] 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 [7] 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 [8]. 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 [9].
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 [1]. 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 [10].
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:
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- 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” [11].
References
[1] Geffen, N. (2012) Getting circumcision science right in the media. http://www.quackdown.info/article/getting-circumcision-science-right-media/
[2] 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
[3] 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
[4] 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
[5] 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
[6] 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
[7] 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
[8] 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/
[9] 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/
[10] 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
[11] www.motherjones.com/mixed-media/2011/08/sf-circumcision-ban-matthew-hess-foreskin-man-comic
“Circumcision’s Psychological Damage”? Not so fast O’Connor & Narvaez!
Posted 17 February 2019
An article often cited by intactivists in support of their oft-repeated assertion that circumcision causes psychological harm is the opinion piece by Patrick O’Connor and Darcia Narvaez which was posted on the popular blog “Psychology Today” in 2015: https://www.psychologytoday.com/us/blog/moral-landscapes/201501/circumcision-s-psychological-damage
But all is not as it appears with this article by a pair of circumcision opponents. A more detailed look at their sources finds that they are weak, misinterpreted or unreliable. In addition, studies that contradict the authors are simply ignored. This is a familiar story for those of us who sacrifice our time to investigate the claims of the anti-circumcision crusaders.
For a detailed, point-by-point debunking of O’Connor and Narvaez, we are indebted to Andrew Gross of the Circumcision Choice team. His rebuttal may be found by following the link below. Enjoy!
https://www.circumcisionchoice.com/single-post/psychological
It’s mutilation!
December 2019
Intactivists love to call circumcision “mutilation”. One might be forgiven for thinking that this is their favourite word, such is the frequency with which it is deployed in their polemics. It conjures up images of harm and disfigurement and makes it easier to make the false analogy with female genital mutilation. This may be a great debating ploy, but it is nothing but a cheap attempt to score emotional points.
In the broadest sense any permanent bodily alteration might be construed as “mutilation”, in which case a vaccination that leaves a scar (as some do) would be a mutilation, albeit trivial. But in the usual sense, “mutilation” is taken to mean harm and disfigurement, as alluded to in the preceding paragraph. Or, to use a dictionary definition: “disfigurement or injury by removal or destruction of any conspicuous or essential part of the body.”
Lest anyone doubt this choice of definition, they should note it is the one chosen by leading intactivists Denniston, Hodges and Milos (1999) who derived it from Stedman’s Medical Dictionary. So, for the sake of argument, we will stick with it.
The problem with this argument is that it is based on two premises: that circumcision disfigures, and that circumcision injures. And both premises are false.
Does circumcision disfigure?
Dealing with the first premise first, does circumcision disfigure? Of course, if it is bodged in some way, then indeed disfigurement may result. But the vast majority of circumcisions are not bodged and when something does go wrong it is usually trivial, and easily and fully resolved. Serious mishaps, such as partial amputation of the glans, are, thankfully, vanishingly rare (El Bcheraoui, et al 2014). For the purposes of this discussion we refer to circumcisions done properly, by trained practitioners, and without mishap. That is practically all of them in developed countries, and increasingly so in developing ones too.
What constitutes “disfigured”, like all aesthetic matters, includes an element of subjectivity, but that does not mean it cannot be objectively studied. And it has been. There are a bunch of studies on the aesthetic preferences of men and women, gay and straight, when it comes to the male organ. Thus:
In a survey of U.S. women, 90 % thought the circumcised member “looks sexier”: Williamson & Williamson (1988).
77 % of women and 80 % of men considered the circumcised member to be better in appearance, in a study in Kenya: Young et al (2012).
83 % of gay men thought the circumcised organ looks better, in a study from Columbia: Gonzales et al (2012).
Health care workers and parents thought that the circumcised member was “aesthetically pleasing”, in a study in Zimbabwe: Mavhu et al (2016).
“Participants consistently described MC as more sexually desirable to women because of increased virility and a more attractive penis”, in a study in Tanzania: Plotkin et al (2013).
94.8 % of men were “very satisfied with post-circumcision appearance of the penis”, in a study in Kenya & Zambia: Sokal et al (2014).
Participants in a study in Botswana reported better self-esteem about the appearance of their penis after circumcision: Wirth et al (2016).
Improved penile appearance was cited as a (minor) reason to get circumcised by Chinese men: Yang et al (2012).
99 % of men circumcised in the course of a study in Kenya were “satisfied with the appearance of their penis”: Feldblum et al (2014).
And this list is not exhaustive. In their extensive review of women’s preferences, Morris et al (2019) found four more studies (in U.S., Canada, Australia and Zambia) in which women preferred the appearance of the circumcised member. And in nearly all studies (29 of them) women, often quite strongly, preferred the circumcised member for cleanliness, health and sexual pleasure. This was true irrespective of the prevalence of circumcision in their societies, and the studies were often of women who had experience of both types of organ.
So, consistently, across continents and cultures (often non-circumcising ones) majorities of both genders say that the circumcised organ looks better. And many think it has other advantages too. Circumcision is not disfiguring; it is an improvement!
Does circumcision injure?
There is a temporary injury when the operation is performed, but that heals in weeks (faster for infants). What matters is permanent harm, and intactivists expend great amounts of time and energy peddling arguments, and cherry-picking studies, claiming that it does cause permanent damage. Which is why there is a whole section of this website devoted to showing that these arguments are bogus: http://circfacts.org/function-sensation/
As explained in the Introduction to that section, there is a large body of good quality evidence demonstrating that circumcision has no adverse effect on sexual function, pleasure or satisfaction. In short, regardless of the speculations and pseudoscience of the intactivists, circumcision, done properly, does no permanent harm and does not constitute lasting “injury”.
As circumcision neither disfigures, nor permanently injures, it is not mutilation.
Bad logic.
The problems with the “mutilation” claim do not end there. As explained in the Sloppy Logic section, the argument is also an example of the Appeal to Emotion fallacy, and the Equivocation fallacy. When compared to female genital mutilation (which often deserves the epithet) it becomes a fallacy of False Equivalence. If that is not enough, “mutilation” is a very value-loaded word. It carries an implication of being ethically wrong, thus presupposing the very thing the intactivists are trying to prove, thus introducing circularity into the argument. But logic never has been intactivists’ strong point.
And still there are problems. As pointed out by Benatar & Benatar (2003a), even disfiguring (hence “mutilating”) medical procedures can have net benefit, citing as an example, the amputation of a gangrenous leg. They write:
“Where a mutilation is, all things considered, a benefit, it can be morally justifiable. Thus, even if circumcision is a mutilation, it does not inevitably follow that it is morally unacceptable. Further argument would be required to establish that conclusion. Although nobody would suggest that circumcision can save a life as directly as can amputation of a gangrenous leg, it is also the case that circumcision, if a disfigurement at all, is a much less radical disfigurement than a limb amputation. The benefit it would have to produce in order to be justified would thus need to be much smaller.”
In short, even if circumcision is mutilation the conclusion that it is therefore morally wrong still does not follow, it is a non-sequitur. The ability of intactivists to cram multiple logical fallacies into a single argument is impressive.
Predictably Benatar & Benatar’s discussion of “mutilation” elicited indignant objections from the anti-circumcision brigade but, as Benatar & Benatar showed in their detailed response (2003b), those objections were largely irrelevant or missed the point. Again, the intactivists’ poor grasp of logic showed.
Intactivists cannot let go of the “mutilation” claim. No amount of rational argumentation or scientific evidence will sway them. It is a central tenet of their faith. A dogma that is impervious to reason.
Just how silly the “mutilation” claim really is was neatly summed up by the Circumcision Choice team in the following meme.
References
Benatar, M. & Benatar, B. (2003) Between prophylaxis and child abuse: The ethics of neonatal male circumcision. American Journal of Bioethics, 3(2), 35-48. On-line abstract: https://www.ncbi.nlm.nih.gov/pubmed/12859815
Benatar, D. & Benatar, M. (2003b) How not to argue about circumcision. American Journal of Bioethics, 3(2). W1-W9. On-line: https://pdfs.semanticscholar.org/d669/3d16c041ddebeed469ea0a440614b5ed0cbc.pdf
Denniston, G.C., Hodges, F.M., Milos. M.F. (1999) Preface in, Male and female circumcision: Medical legal and ethical considerations in pediatric practice, ed. Denniston, G.C., Hodges, F.M., Milos, M.F., i–vii. New York: Kluwer.
El Bcheraoui, C., 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 Pediatr., E1-E10. On-line: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4578797/
Feldblum, P.J., Odoyo-June, E., Obiero, W., Bailey, R.C., Combes, S., Hart, C., Lai, J.J., Fischer, S., Cherutich, P. (2014) Safety, effectiveness and acceptability of the PrePex device for adult male circumcision in Kenya. PLoS One, 9(5), e95357. On-line: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4006910/
Gonzales, F.A., Zea, M.C., Reisen, C.A., Bianchi, F.T., Betancourt Rodríguez, C.F., Aquilar Pardo, M., Poppen, P.J. (2012) Popular perceptions of circumcision among Colombian men who have sex with men. Culture Health & Sexuality, 14(9), 991-1005. On-line: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3463718/
Mavhu, W., Hatzold, K., Ncube, G., Fernando, S., Mangenah, C., Chatora, K., Mugurungi, O., Ticklay, I., Cowan, F.M. (2016) Perspectives of parents and health care workers on early infant male circumcision conducted using devices: Qualitative findings from Harare, Zimbabwe. Global Health: Science & Practice, 4, Supplement 1, S55-67: On-line: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4944580/
Morris, B.J., Hankins, C.A., Lumbers, E.R., Mindel, A., Klausner, J.D., Krieger, J.N., Cox, G. (2019) Sex and male circumcision: Women’s preferences across different cultures and countries: A systematic review. Sexual Medicine, 7(2), 145-61. On-line: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6523040/
Plotkin, M., Castor, D., Mziray, H., Küver, J., Mpuya, E., Luvanda, P.J., Hellar, A., Curran, K., Lukobo-Durell, M., Ashengo, T.A., Mahler, H. (2013) ‘‘Man, what took you so long?’’ Social and individual factors affecting adult attendance at voluntary medical male circumcision services in Tanzania. Glob. Health Sci. Pract., 1(1), 108-16. On-line: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4168557/
Sokal, D.C., Li, P.S., Zulu, R., Awori, Q.D., Agot, K., Simba, R.O., Combes, S., Lee, R.K., Hart, C., Lai, J.J., Zyambo, Z., Goldstein, M., Feldblum, P.J., Barone, M.A. (2014) Field study of adult male circumcision using the ShangRing in routine clinical settings in Kenya and Zambia. J. Acquired Immune Deficiency Syndrome, 67(4), 430-70. On-line abstract: https://www.ncbi.nlm.nih.gov/pubmed/25162816
Williamson, M.L. & Williamson, P.S. (1988) Women’s preferences for penile circumcision in sexual partners. J. Sex Education & Therapy, 14(2), 8-12. On-line abstract: https://www.tandfonline.com/doi/abs/10.1080/01614576.1988.11074930
Wirth, K.E., Semo, B.W., Ntsuape, C., Ramabu, N.M., Otlhomile, B., Plank, R.M., Barnhart, S., Ledikwe, J.H. (2016) Triggering the decision to undergo medical male circumcision: a qualitative study of adult men in Botswana. AIDS Care, 28(8), 1007-12. On-line abstract: https://www.ncbi.nlm.nih.gov/pubmed/26754167
Yang, X., Abdullah, A.S., Wei, B., Juang, J., Deng, W., Qin, B., Yan, W., Wang, Q., Zhong, C., Wang, Q., Ruan, Y., Zou, Y., Xie, P., Wei, F., Xu, N., Liang, H. (2012) Factors influencing Chinese male’s willingness to undergo circumcision: A cross-sectional study in Western China. PLoS One, 7(1): e30198. On-line: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3257276/
Young, M.R., Odoyo-June, E., Nordstrom, S.K., Irwin, T.E., Ongong’a, D.O., Ochomo, B., Agot, K., Bailey, R.C. (2012) Factors associated with uptake of infant male circumcision for HIV prevention in western Kenya. Pediatrics, 130(1), e175-8. On-line: https://www.ncbi.nlm.nih.gov/pubmed/22711723
Regulation, not prohibition
Posted 10 January 2021
Anti-circumcision sentiment is common amongst secular humanist, atheist and skeptic groups. Being frequently a religious practice it is likely they see it as a convenient stick to bash religion with. They should not be so quick to judge. One of the CircFacts team, himself an atheist, wrote the following article which was published in the on-line magazine “The Pink Humanist”, which targets the LGBT humanist community in the UK. For a while it was freely available on-line, but recently the magazine was taken off-line. But we thought the article was too good to lose, so it is reproduced here. Enjoy!
Doctors Opposing Circumcision lie about HIV
Posted 31 January 2021
“Doctors Opposing Circumcision” (DOC) posted on their website an item about circumcision and HIV dated 5th July 2016 and updated in September 2020. Here is the link: HIV/AIDS | Doctors Opposing Circumcision But it merely repeats tired old arguments that were debunked years previously in the scientific literature – debunkings that DOC, in typical intactivist fashion, simply ignores. To “re-debunk” every claim in their mendacious article would require another full-size article but, as they have already been comprehensively debunked in the scientific literature by experts, instead they are simply listed below along with an answer comprising either a brief rebuttal, or a link to where a detailed refutation can be found.
DOC: “Dowsett and Couch examined the results of the three RCTs, but found insufficient evidence to recommend circumcision to prevent HIV infection”
Answer: Dowsett and Couch’s opinion was not shared by the Cochrane review committee who examined the same results and concluded that the evidence was sufficient: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003362.pub2/epdf/full Dowsett and Couch nevertheless agreed that “the evidence of a protective effect of male circumcision is compelling”.
DOC: “Green et al. reviewed the evidence and also found “insufficient data” as well as contrary evidence”.
Answer: DOC cites two articles by (in part) the same authors, and with some overlap in the arguments made. The first was subject to a detailed, point-by-point rebuttal by 48 experts, researchers and front-line workers: untitled (futuremedicine.com) The second was rebutted by two separate groups of experts: Male Circumcision As a Component of Human Immunodeficiency Virus Prevention – American Journal of Preventive Medicine (ajpmonline.org) (behind a paywall) and Circumcision_Denialism_Unfounded_and_Unscientific_AJPM.pdf (ghdonline.org) The title of the latter was damning: “Circumcision denialism unfounded and unscientific”.
DOC: “The three African RCTs were very similar in study design and contained multiple sources of bias, outlined below” DOC then gives four references (their refs 89-92).
Answer: All four of these references were subject to detailed debunkings. 89 & 90 are the two referred to above. Reference 91 was debunked here: Criticism of African trials fail to withstand scrutiny and their reference 92 was debunked here: Exposé of misleading claims that male circumcision will increase HIV infections in Africa (nih.gov) The list of alleged “sources of bias” that follow are all addressed in the aforementioned rebuttals.
DOC: “The cumulative treatment effect in these trials – which claimed a 38-66% relative risk reduction[99] – was an absolute risk reduction of 1.3%”.
Answer: As explained here: https://www.tandfonline.com/doi/abs/10.1080/17441692.2016.1164737?journalCode=rgph20 and here: HIV/AIDS – CircFacts.Org that “1.3%” is actually very good and translates into 13% after 20 years. It is also comparable to the efficacy of influenza vaccine against the flu.
DOC: “Data released before the trials began found a number of African countries where the prevalence of HIV infection was greater in circumcised men than in intact men.” Two references (100 & 101) are given.
Answer: Their reference 100 is part of the Demographic and Health Surveys (DHS) Program and the intactivist abuse of it is debunked in detail here: HIV/AIDS – CircFacts.Org Their reference 101 also relies upon DHS data, so the same problems apply.
DOC: “Since the mass circumcision campaigns began in Uganda and Kenya, the incidence of new cases of HIV in both countries has increased.[102-104]”
Answer: Their reference 102 contradicts DOC by citing a 2012 paper that “showed that scaling up medical circumcision in Rakai district led to a reduction of HIV acquisition by circumcised men”. Nor does their reference 103 support their claim. It points out that the province of Kenya with the highest HIV incidence, Nyanza, has the lowest level of circumcision. Also, the same report points out that 45% of recipients of circumcision have been <15 years old. Most of these boys will not yet be sexually active, so there will be a time lag of a few years before the benefit of their circumcision is manifest. Reference 104 is a newspaper report that prevalence, not incidence, of HIV had risen in Nyanza province. That DOC do not know the difference between prevalence and incidence is unsurprising when one realises that many of DOC’s members are not doctors. HIV prevalence rises when Anti-Retroviral Therapy (ART) is rolled out as people who previously would have died of AIDS are now living with HIV. ART is being rolled out in Kenya, alongside circumcision, so it is unsurprising that HIV prevalence is increasing.
DOC: “there is no evidence that circumcision has had any impact on lowering the incidence of HIV infection in the United States”
Answer: This ignores the fact that circumcision is only effective against female to male transmission, and most transmission in the USA is in other ways. It is also untrue as explained in the concluding paragraphs here: http://circfacts.org/medical-benefits/hivaids/#hiv4
DOC: “Of the eight HIV studies in North American heterosexual men, [100,106-112] only one has found a significant association between circumcision and HIV infection risk: it actually found that circumcised men were at greater risk of HIV infection.[112]”
Answer: Reference 100 does not even cover America. 106 did not study circumcision. 107 did find that circumcision was protective against HIV (p = 0.04) thereby contradicting DOC. 108 does not mention HIV. 109, a study of US Navy personnel, was criticised by the CDC who pointed out the unreliable methods used to determine HIV and circumcision status, and problematic assumptions made: Summary of Public Comments and CDC Responses to Public Comments (page 2). 35.5% of participants in 110 were gay/bisexual, and the study likely lacked the statistical power to detect a protective effect in the heterosexual participants in a country with a relatively low HIV prevalence. 111 did find a protective effect amongst patients known to have been exposed to HIV (as opposed to those not known to have been exposed), thereby contradicting DOC. And 112 was subsequently discredited: Faulty Analysis Leads to Erroneous Conclusions – KLAUSNER – 2013 – The Journal of Sexual Medicine – Wiley Online Library (behind a paywall). So, of the 8 studies cited, 3 are irrelevant, 2 are limited or weak, two contradict DOC, and one has been discredited. This is just another example of pseudoscientists’ dishonest habit of using misleading citations to give their bogus claims a veneer of credibility: Sloppy Logic – CircFacts.Org
DOC: “[Langerhans] cells produce a protein, langerin, that is actually protective against the virus”.
Answer: At high viral loads the cells and their langerin are simply overwhelmed: HIV/AIDS – CircFacts.Org
DOC: “RCTs carried out among adults in Africa are not relevant to children anywhere, since children are not sexually active and are therefore not at risk of HIV infection by sexual transmission.”
Answer: This is the “Babies don’t have sex” argument answered here: http://circfacts.org/general-information/#med2 Is it also an argument for not giving HPV vaccine to under-age kids.
DOC: “condoms are an effective means of preventing sexually transmitted infections, including HIV.”
Answer: Condoms are insufficient: General Information – CircFacts.Org
DOC: “Other preventative interventions, such as “treatment as prevention,” pre-exposure prophylaxis (PrEP),[176] and post-exposure prophylaxis (PEP)[177] are more effective, less expensive, and less injurious than circumcision.[118,119]”
Answer: “Treatment as prevention” is a reference to ART, but that is for people already infected with HIV, circumcision is about preventing infection in the first place. Do DOC really prefer that people get infected then embark on costly, unpleasant, life-long ART rather than get circumcised? PrEP and PEP have the same weaknesses as condoms – they rely on every sexually active person using them, using them consistently, and using then properly every time they do. All run the risk of resistance developing, and all have side effects. Nor are they less expensive. Circumcision is a cheap, one-off intervention that lasts for life. The others all require regular doses, the costs of which soon add up, ART especially: Benefits and Costs of the HIV/AIDS Targets for the Post-2015 Development Agenda (copenhagenconsensus.com). And circumcision is not injurious other than for the short healing period. ART, however, has unpleasant side effects including potentially serious renal, blood sugar, and cardiac issues, and is for life. Of the 4 references cited three (119, 176, 177) are about ART, PrEP & PEP respectively, not circumcision. And 118 is a conference abstract describing a modelling study using assumed efficacies to compare ART, circumcision and condoms. All three were efficacious, with ART & condoms best.
Conclusions
The article on the DOC website about circumcision and HIV is dishonest and deceptive. It systematically ignores detailed debunkings of the claims made and the intactivist sources it cites. Its references are selective, and misleading. Its statements often false and discredited. It is pure pseudoscience.
But that is to be expected of an organisation that is, in fact, bogus. Doctors Opposing Circumcision is an example of a false authority: http://circfacts.org/sloppy-logic/#slog2 Many of its top officers are not doctors at all. In 2013 it was publicly challenged to reveal how many members it has, and how many are actual doctors: eLetters | Journal of Medical Ethics (bmj.com) and the same author (yours’ truly) also asked them privately. No response.
Pseudoscientists have a habit of trying to give their nonsense respectability by setting up professional-sounding outfits. Examples include:
The “American College of Pediatricians” (ACP). A few hundred pediatricians with religious, right-wing views hostile to LGBT people. The ACP has been caught out repeatedly distorting scientific data, spreading lies about LGBT people, and promoting quack “therapies” to “cure” them. It is recognised as a hate group.
The “Population Research Institute”. Denies overpopulation and anthropogenic climate change, and opposes birth control and abortion. Its founder was a Catholic Priest with a history of anti-Semitic remarks, and it is now run by an anti-abortion activist who was expelled from Stanford University for unethical conduct. It has recently taken to peddling COVID-19 conspiracies.
The “Association of American Physicians and Surgeons”. Another homophobic, anti-abortion ultra-conservative outfit, and home to assorted HIV/AIDS deniers, climate change deniers, anti-vaxxers and opponents of universal health care.
Anti-vaccination groups with names like “National Vaccine Information Center” and the (happily now defunct) “Children’s Medical Safety Research Institute”, and a plethora of creationists hiding behind names like “Truth in Science”, “Discovery Institute” and “Geoscience Research Institute”.
Don’t be fooled by the name. “Doctors Opposing Circumcision” is no more credible than any of these other crank outfits. For more on DOC see: https://www.circumcisionchoice.com/single-post/__doc
Jonathan Meddings and “The Final Cut”: when a rationalist abandons reason.
A review of Jonathan Meddings (2022) “The final cut: The truth about circumcision”. Privately published. ISBN: 978-0-6453682-0-8
Reviewed by Dr Stephen Moreton PhD. Posted January 2024.
Jonathan Meddings is an Australian writer whose website https://www.jonathanmeddings.com/ describes him as a human rights advocate with a degree in medical laboratory science. He was also, for a while, vice-president of the Rationalist Society of Australia, which claims to support science and reason. As the reader will see from what follows, this cannot be said of Meddings. His book comprises 10 chapters. However, I have decided to only cover the first three of these. Why so? Well, it took me five days just to get through those first three chapters as nearly every statement in them was misleading or one-sided, and had to be tediously fact-checked, along with his citations. Rebuttals to those citations had to be checked, along with literature searches to find other works he had ignored. And the whole lot had to be written up and formatted for this website. As I have other things to do, and a life to lead, I did not fancy spending another fortnight going through the rest of his tedious nonsense. Besides, it is not necessary to refute every claim. I refute more than enough to show that Meddings cherry-picks his way through the data and literature, ignoring critiques of the studies he cites, ignoring high quality research that contradicts his agenda, citing articles that do not support his claims, makes claims that are misleading or just plain false, and uses sloppy logic – the false analogy being his favourite fallacy. In short, his book is hopelessly biased pseudoscience, badly researched, and written to further an anti-medical science agenda. My strong recommendation is: Do not buy it!
What follows are my notes and findings in chronological order as I came across his half-truths, falsehoods, omissions, and selective citations. I apologize for the length, but that reflects the sheer volume of baloney Meddings has crammed into his book. Besides, who will have the time, or inclination, to read a debunking of all ten chapters? It would require a separate, and extensive, book for that.
CHAPTER 1: Cutting to the chase: an introduction.
Page 6: The very first sentence reads, “A distraught mother broke down in court, tears streaming down her face, her hands handcuffed and shaking, as she was forced to sign a consent form allowing her child’s genitals to be mutilated.” This referred to the “Heather Hironimus” case. The reader is immediately subjected to emotive language, such as the term “mutilation” – a misnomer, as I will explain below. Meddings makes this hyperbolic statement in the absence of any attempt (yet) to justify his contention that circumcision is “mutilation”. Doing so bodes ill for what else he writes in his book.
A couple of paragraphs later the appeal to emotion repeats, “And so it was that a court in the United State of America, in 2015, ordered the genitals of a young boy to be mutilated, and they duly were.” A false analogy is then made with female genital mutilation (FGM).
Page 7: The author claims that those who “think male circumcision is not a form of genital mutilation” are “wrong” and continues the false analogy with FGM. I will return to this theme shortly.
In referring to the number of circumcised males in the world, he writes, “That is almost 1.2 billion men missing the most sensitive part of their penis”. Most sensitive with respect to what? Pain? Temperature? Stretch? It is not the most sensitive part across all sensation types (Bossio et al., 2016). Intactivists harp on about fine-touch sensitivity, but the foreskin’s sensitivity in this regard (at least the part tested) is similar to that of the forearm (Bossio et al., 2016). Fine-touch is irrelevant, it is erogenous sensation that matters (Cox et al., 2015) and the foreskin is the least erogenous part of the penis (Schober et al., 2009; Claeys et al., 2023). Meddings ignores these studies.
Meddings goes on to use more emotive language in stating that “in the US, where every year more than a million baby boys are strapped to plastic boards to have their foreskins ripped, clamped, crushed and cut off.” More emotive and exaggerated claims follow about complications, sexual and psychological issues, and repeats the falsehood about the foreskin being the “most sensitive part of their penis”. So, we are not even past the first two pages and already we have been regaled with appeals to emotion, a fallacy of false equivalence, and misleading claims about sensitivity.
Then comes “A population-based study in Denmark estimated that a mere 0.5% of intact males require a circumcision for medical reasons before age 18” citing Sneppen & Thorup (2016). But this is misleading. In that study, 1.7% of boys required some form of surgery, whether foreskin-preserving (preputioplasty) or circumcision. For preputioplasty, 6.7% (9 in 137) failed, leading to a subsequent circumcision, thus subjecting those boys to two surgeries when one (circumcision) would have sufficed. And this percentage applied only for boys < 18 years old. The lifetime risk will obviously be much higher. Nor does it account for the many more boys who experience foreskin problems requiring other interventions, nor the discomfort those boys must suffer. See also: https://www.circumcisionchoice.com/single-post/2016/12/01/is-circumcision-worthless-for-996-of-boys
Pages 8-9: Here he attempts to justify using the word “mutilation” to convey “appropriate connotations of harm”, but circumcision does not constitute “harm”, Meddings’ bogus claims notwithstanding.
Page 10: Meddings claims that the medical benefits are “at best negligible and at worst non-existent”, which is false. He also argues that these benefits are “beside the point” because the procedure “violates medical ethics when performed on children too young to consent”, thus revealing that his position is essentially an ideological one. Even if the benefits were substantial and proven (which they have been) he’d still be opposed to infant circumcision. He is clearly an ideologue, not a rationalist.
CHAPTER 2: Not just a little snip.
Page 12: This begins with an emotional description of screaming babies, ignoring the fact that infant circumcision is now normally done with a local anaesthetic.
He says, “The quiet ones are likely quiet because they’re in a state of trauma-induced shock” citing Rhinehart (1999) and Svoboda & Van Howe (2013). But this is nonsense. In medicine, shock is a serious, life-threatening condition associated with a sudden and severe drop in blood pressure. Medical staff are trained to spot and deal with it immediately. If this is what quiet babies were experiencing, the staff would surely notice. Turning to the sources he cites, Rhinehart (1999) is an anecdotal opinion piece without a jot of clinical evidence that physiological shock occurs during circumcision. Svoboda & Van Howe (2013) merely assert that babies go into shock, without providing evidence. Thus, the citations Meddings provides do not support the claim. The reason babies (at least those in receipt of local anaesthesia) are quiet is because they are not feeling anything.
Then he goes on to state “Circumcision also involves the removal of 30-50% of the penile skin”, citing an intactivist book rather than a peer-reviewed scientific source. However, since this is a common intactivist claim it has already been examined and exposed as misleading here: https://circfacts.org/function-sensation/#sens12
What follows is: “which if left to grow would average about 5 to 8 square inches in the adult”. Correct! But the caveat to this statistic is that this figure is for the combined surface area of both inner and outer foreskin.
Page 13: The author embarks on a discussion of what constitutes “mutilation”, choosing the Oxford English dictionary definitions “to inflict a serious and disfiguring injury” and “to inflict serious damage”. He then adds his own definition, “a physically harmful, and also often psychologically harmful and/or disfiguring injury”. But medical circumcision does not meet any of those criteria. There is a minor injury, but it heals within a week or two (around 6 weeks for an adult), there is no lasting harm as evidenced by multiple studies (https://circfacts.org/function-sensation/#sens0 ) which the author ignores. And as most people, male and female, gay and straight, prefer the circumcised look, even in non-circumcising cultures, it is not disfiguring either (see references here: https://circfacts.org/debunking-corner/#debk7 ). The “mutilation” claim has been thoroughly debunked: https://circfacts.org/debunking-corner/#debk7. The author is deliberately choosing emotive language. Why can’t he just rely on the scientific evidence instead?
Pages 14-15: The author continues the false analogy with FGM by pointing out, correctly, that some forms of this are very minor, more minor even than male circumcision. But he ignores the crucial point that no form of FGM imparts any significant medical benefit, whereas male circumcision does. This key difference renders the analogy false.
Pages 16-17: In a section entitled “Functions of the foreskin” the author trots out the usual, tired old canards that those of us familiar with intactivist claims have heard (and debunked) ad nauseam. Thus:
Sensitivity. Again, the assertion that the foreskin is “the most sensitive part of the penis” is repeated but with a little more detail – “with an abundance of specialized fine-touch receptors making it highly sensitive to sexual stimulation”. But this is irrelevant. Fine-touch comes mostly from receptors called Meissner’s corpuscles, and although these have been found in the foreskin, the literature on them is somewhat mixed, with some studies finding them, some not, one finding that they tend to disappear after puberty, and another finding more (and larger) ones in fingertips (one does not get an orgasm by rubbing fingertips). The review by Cox et al. (2015) summarizes the situation nicely. As explained previously, it is erogenous sensation that matters, and whatever the receptors responsible for that are, they are not the fine-touch ones, and the foreskin is the least erogenous part of the penis. Meddings continues his theme by referring to the “gliding action”, another intactivist favourite debunked here: https://circfacts.org/function-sensation/#sens4 – and then refers to the “complex sensory interaction between the head of the penis and the foreskin”, citing Cold & Taylor (1999), despite this having been long ago dismissed as unproven speculation (Alanis & Lucidi, 2004).
Adequate skin coverage. Meddings asserts that the foreskin “provides adequate skin to cover the shaft of the penis during an erection”, alleging that without it “painful, shorter and curved erections” may result, citing Cold & Taylor (1999), Richters et al. (1995), and Van Duyn & Watt (1962). However, the claim is not well support by those references. Cold & Taylor’s paper, as rich in descriptive detail as it is in rampant speculation about what it all means, is silent on shaft coverage, penile length, or curvature. Richter’s did report that circumcised organs had erections on average 8 mm shorter than non-circumcised ones and speculated that this may be due to some having insufficient remaining skin, but they did not control for age. If, as is likely, their older participants were also more likely to be circumcised they may have had weaker erections than the study’s youthful participants. Van Duyn & Watt (1962) is a case report in which an infant had too much skin removed, and in which they do say this can result in a shorter organ. But this is a criticism of the competence of the operator, not the procedure per se. For the overwhelming majority of circumcised males there is no problem.
Facilitated intromission. This is where Meddings descends into comicality. Circumcision increases the force required for vaginal penetration “tenfold” he claims, citing Taves (2002). Taves’ article (I am reluctant to call it a “study”) described his attempts to copulate with a hole cut in the base of a Styrofoam cup mounted on a balance. He found it harder with his foreskin retracted. So, Meddings actually believes that a hole in a cup is a realistic model of a human vagina! Yes, really! It is hard to take him seriously if that is what he thinks. In fact, foreskins impede intromission. It has been reported across multiple, high-quality studies, using actual vaginas (i.e. consenting couples), that circumcision makes penetration easier, there is less pain on intercourse, and fewer coital injuries. See https://circfacts.org/function-sensation/#sens9 and https://www.circumcisionchoice.com/single-post/styrofoamvagina to find out just how wildly wrong the claim is, and how utterly ridiculous is the only reference Meddings can scrape out of his barrel to support it.
Reduced friction. Related to the above and just as baseless, being contradicted by high quality studies (randomized controlled trials, cohort and case control studies, systematic reviews and meta-analyses) cited here: https://circfacts.org/function-sensation/#sens9. As usual, the citations Meddings provides are inadequate – Bensley & Boyle (2003); Frisch et al. (2011), and O’Hara & O’Hara (1999) – all authored by circumcision opponents (quelle surprise!). The first is a letter to the editor, describing a survey (Bensley & Boyle’s ref. no. 5) in which just 160 responded despite 553 surveys having been distributed, and only 35 were female respondents. To anybody with even a rudimentary understanding of study design this should set alarm bells ringing. Cross-sectional study designs with such poor response rates are notoriously prone to selection bias (https://sph.unc.edu/wp-content/uploads/sites/112/2015/07/nciph_ERIC13.pdf ), and the response rate here is so abysmal as to render it close to worthless. Selection bias is also likely in the second study, by Frisch et al. But this had other methodological problems summarized by Morris et al. (2012) and added to by the late Prof. Michael King (2011) who described the effect as “tiny” and “overanalysed”. As indeed it is. The raw data show no obvious difference, it was only after some statistical jiggery-pokery that the authors squeezed out an apparently significant effect for “frequent” orgasm difficulties. But one does not have to be a statistician to know that with just 10 out of 95 circumcised men experiencing “frequent” orgasm difficulties it may be numerically unstable. Similar arguments apply to the female participants, for whom the results were barely statistically significant. Perhaps in recognition of this, Frisch has gone on record stating that most circumcised men and their partners have no problems (https://www.youtube.com/watch?v=yfGkZZ-KzpU&t=98s ). What should be the final nail in the coffin of this mediocre study came from another Danish epidemiologist who pointed out that most circumcised Danish men received the procedure to treat a medical problem, thus raising the possibility that the 10 affected men in the Frisch study were experiencing some legacy of whatever problem it was that they were circumcised for (Meyrowitsch, 2019). As for O’Hara & O’Hara, their hopelessly biased survey has been debunked in detail here: https://www.circumcisionchoice.com/single-post/ohara Meddings ignores all these critiques.
Immune defense. Another misleading claim. All skin contains immune cells etc. Of course –after all, it is often the body’s first line of defence against infection. But if the foreskin is so good at defending against infections, then why does Meddings’ own citation (Iwosaki, 2010) state, “circumcision significantly reduces STI rates in men” and, “Accumulating data suggests that male circumcision has long-term beneficial health effects on both males and females by limiting the spread of STIs”? Does Meddings not read the papers he cites?
Physical protection. This might be plausible for naked tribesmen wading through long grass and prickly bushes, but even circumcised naturists get by happily without foreskins. And most of us wear clothes. Meddings also claims foreskins protect against “contamination” citing the aforementioned, speculation-riddled, Cold & Taylor (1999). Contamination by what? Certainly not the pathogens responsible for the wide range of infections circumcision protects against.
Interestingly, the above list of putative functions is taken verbatim from an earlier work by Meddings & Wisdom (2017). Evidently, in the intervening years Meddings has never bothered to fact-check any of it. Once intactivists settle on a falsehood they tend to just stick with it, ignoring criticisms, and ignoring contrary information, instead reading only whatever materials they encounter in their own little echo chambers, a phenomenon known to psychologists as “confirmation bias”.
Page 17: “without a foreskin the exposed head of the penis becomes chafed and dried out, causing it to harden (or keratinize)”. There is not a jot of evidence for this. In fact, what scant evidence there is indicates keratinization does not happen (https://circfacts.org/function-sensation/#sens3 ). The reference Meddings provides (Iwosaki, 2010) is ambiguous on this point, and provides no measurements in support. That is because there aren’t any.
Page 18: A section about penile sensitivity and sexual function opens with an admission that the evidence for the effect of circumcision on these is mixed. Meddings then harps on about fine-touch, although as we have seen this is irrelevant. It is erogenous sensation that counts, and that is mostly found in the glans and underside of the distal shaft. So, Meddings has gone off the rails. Predictably he goes on to cite Sorrells et al. (2007), a study paid for and conducted by intactivists, but which only looked at fine-touch, not erogenous sensation, thereby rendering it irrelevant. Equally predictably, Meddings ignores the criticism it attracted for flaws in its methodology and statistical analysis (Waskett & Morris, 2007).
Page 19: Meddings objects to two randomised controlled trials (RCTs) in which circumcision had no effect on sexual outcomes, citing Frisch (see Morris et al., 2012 in the references below), in whose opinion some of the questions used were inadequate. But that is mere opinion, and not an impartial one either (Frisch is vehemently anti-circumcision). It also misses the point that the same questions were asked of both intervention and control groups. If circumcision was even a fraction as bad as intactivists claim, it would have shown up. It didn’t. Meddings also complains about condoms being available to the participants. So what? The same condoms, at the same clinics, were equally available to all participants, and published data in parallel studies (three RCTs on HIV: Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007) on the same subjects showed that they used condoms with the same frequency. He is clutching at straws here.
Meddings then gets his knickers in a twist over a finding in one RCT (Krieger et al., 2008) that circumcised men found condoms “easier to use”. Yet this has been observed across multiple studies. Consistently, circumcised men find condoms easier to use and less likely to fail (Riess et al., 2010; Grund and Hennick, 2012; Feldblum et al., 2015; Bailey et al., 2002; L’Engle et al., 2014). Some intactivists are so dedicated to their narrative that circumcision is all things bad that they cannot tolerate ANY benefit from it, no matter how minor. Thus, in the mind of the intactivist, circumcision can’t make condoms easier to use. To them, it just can’t. Never mind the evidence now replicated across half a dozen independent studies. It just can’t!
This obstinate refusal to consider anything that contradicts the intactivist narrative is apparent again when Meddings writes (pages 21-22) that it “defies logic, common sense and the best available evidence that circumcision, in its removal of highly sensitive foreskin tissue and subsequent hardening (or keratinization) of the head of the penis, should result in anything other than a reduction of penile sensitivity.” As we have seen this is all baloney. For more on sensation, and what Meddings does NOT tell his readers, see https://circfacts.org/function-sensation/#sens7
Meddings then turns his attention to ejaculation. Most studies find that circumcision has no effect, but Meddings ignores these. A few find a slight delay (which might be considered a boon for those with premature ejaculation) and at least one found it makes achieving ejaculation easier. The simplest explanation is that circumcision has no effect, and all we are seeing with the few studies that find a slight effect is statistical noise. Ignoring the obvious, Meddings talks about the bulbocavernosus reflex which, he says, is absent in circumcised men. So, it is harder to trigger a twitch in their anal sphincter by tweaking their glans. How this reflex can have any bearing on sexual function is difficult to comprehend unless one’s partner bites during oral sex while one is wearing a butt plug. In any case, the observation is based on a single study, on a small sample, and which has never been replicated. A systematic review of the mechanisms of orgasm and ejaculation mentions “prepuce” (another term for foreskin) just once, in passing, and does not say it has anything to do with ejaculation (Alwaal et al., 2015). What makes this review particularly useful is that it is not by noted partisans in the debate, unlike Cox et al. (2015) which also found the foreskin to be irrelevant, but whose authors are noted circumcision proponents.
CHAPTER 3: Cutting to cure?
Meddings turns to the medical benefits of circumcision, opening with the statement that “No professional organization of medical doctors anywhere in the world recommends routine infant circumcision”, a statement which is open to interpretation (https://circfacts.org/general-information/#med5 ). He discounts the WHO, UNAIDS and UNICEF as being “bureaucratic bodies”. Predictably, he attacks the AAP’s (now lapsed) 2012 cautiously pro-circumcision statement, saying “dozens of eminent doctors from around the world published a paper in Pediatrics (the official journal of the AAP) that was highly critical of the AAP’s 2012 policy statement” accusing it of “cultural bias”. What Meddings does not tell us is that 37 of these 38 supposedly “eminent” (says who?) doctors were European, largely north European, with about a third of them from Scandinavian countries. Why so many “Vikings”? It is not hard to guess what happened. Likely, the lead author, Morten Frisch (a Dane) circulated the document around his associates getting them to add their names. But out of 1.8 million medical doctors in the EU he only got 37, plus one Canadian, to sign up. In any case the AAP rebutted the technical criticisms levelled, and turned the “cultural bias” accusation around by pointing out that their critics mostly hailed from lands in which circumcision was unfamiliar in the authors’ culture (AAP Task Force, 2013). Citing their own works, but ignoring the rebuttals of those works, is normal for intactivists, as should be apparent by now. Meddings’ behaviour fits with such “ignore-ance”.
Meddings continues this, by now expected, theme by referring to the criticisms the CDC’s 2014 draft male circumcision policy attracted (thanks to a concerted social media campaign by intactivists: https://circfacts.org/cyber-bullying/#cyber13 which he neglects to mention) whilst ignoring the CDC’s detailed rebuttal of those same criticisms (CDC, 2018).
Page 27: A brief section on the history of circumcision follows. This borders on the genetic fallacy. For example, so what if some Victorian cranks had ideas about the procedure we now recognise as daft? The case for medical circumcision is based on modern science, not bygone quackery. In fact, Victorians turned to circumcision when it was found to reduce the risk of syphilis, which was rampant in Victorian times.
Page 29: Phimosis is likely over-diagnosed, but even using Meddings’ low-end estimate from earlier, around 1.7% of boys will still require some form of surgery for it, and many more will need tedious steroid cream and stretching exercises. Others will develop the problem later in life and need similar interventions. And all must suffer the discomfort of the condition until it is diagnosed and addressed. Prevention is generally considered better than cure. Similar arguments apply to inflammatory conditions which, the author acknowledges, can turn cancerous.
Cervical cancer. Meddings’ discussion of HPV (the virus behind most cases of cervical cancer) is inadequate. He acknowledges that there is some evidence of benefit from being circumcised, but not how much. In fact, circumcision reduces incidence, prevalence and accelerates clearance time for oncogenic strains of HPV, as demonstrated by a voluminous literature conveniently summarized by systematic reviews and meta-analyses (Albero et al., 2012; Rodríguez-Álvarez et al., 2018). The protective effect extends to the female partners of circumcised men (Shapiro et al., 2023). It should be noted that there are scores of different strains of HPV, and it is only the oncogenic (cancer-causing) ones that circumcision protects against, and they affect the distal (head) part of the penis, not the shaft, rendering Meddings’ complaint that the shaft is not affected irrelevant. Meddings also touts an argument by intactivist Robert Van Howe that the apparent benefit is a result of sampling bias “in which only the head of the penis was tested”. But this point is well known to researchers and has been addressed (Auvert et al., 2009; Tobian et al., 2009). Nor are vaccines sufficient on their own. HPV vaccines do not target all 15 oncogenic strains, uptake is poor (thanks in part to anti-vaxxers, many of whom are also anti-circumcision), and vaccine effectiveness may wane with time.
Penile cancer. As with cervical cancer, Meddings omits much important information. It is a medical consensus that circumcision is highly protective against penile cancer, as attested to in multiple reviews of which perhaps the meta-analysis by Larke et al. (2011) is particularly interesting as it found that it was early age (infant or childhood) circumcision that protected, not adult. Meddings points to countries with high circumcision rates yet also high penile cancer rates and vice versa, but such ecological data can be misleading as they are subject to confounding. Nevertheless, in a review of data from 86 countries, it was found that penile cancer was generally lower in countries that practised early age circumcision. In Israel it was near zero (Cardona & García-Perdomo, 2017). Meddings contrasts the incidence of penile cancer in the USA with other countries where circumcision is less common but omits to mention that when it does occur in the USA it is almost exclusively in uncircumcised men (Schoen, 1991). And he denies that smegma (which is difficult to clean away if the man has phimosis) is a risk factor, citing an article by intactivists Van Howe & Hodges (2006) but ignoring the critique of that article (Waskett & Morris, 2008) and also ignoring various reviews finding that smegma, and phimosis, are both risk factors for penile cancer (Morris et al., 2011; Misra et al., 2004; Larke et al., 2011; Marchionne et al., 2017). Meddings is misleading in claiming that “as many as 322,000 circumcisions may be required to prevent just one case of penile cancer”. This statistic is a rough per annum figure (in fairness, the AAP report from which he drew that figure also fails to make this clear). For lifetime protection, the figure is around 909 (mentioned in the same report, so Meddings knew of it). And he makes the ludicrous comparison with removal of breasts or cervix in young girls to prevent the respective cancers. For an exposé of just how stupid (and I mean really, really, mind-numbingly stupid) this comparison is see https://circfacts.org/debunking-corner/#debk3. Meddings does like his false analogies. For more see https://www.circumcisionchoice.com/single-post/cancer, including a discussion of the letter by Shingleton and Heath that Meddings cites.
Clean cut? Here Meddings addresses the argument that being circumcised is more hygienic. This is, perhaps, one of the weaker pro-circumcision arguments, at least in developed world settings where it is easy to simply wash the relevant region (unless an uncircumcised male has phimosis, which is common). Nevertheless, it is a fact, horrible but true, that some guys just don’t bother. I’ll leave it to the reader’s imaginations to imagine the smelly results. A study in London found that, compared with circumcised men, inadequate penile washing was 8-fold more common in uncircumcised men (P < 0.001) and those with balanitis (P = 0.036) (O’Farrell et al., 2005). Further research found that those with longer foreskins were wetter under those foreskins – just how bugs like it. Little wonder they were more prone to inflammatory conditions and infections (O’Farrell et al., 2008). There is a considerable, and growing, body of evidence regarding the microbiome of the penis before and after circumcision. Basically, after the procedure there are fewer harmful anaerobes and fungi, and consequently fewer conditions associated with these, and less inflammation. The recent review by Gonçalves et al. (2022) provides a convenient summary of ten studies covering various ages and nationalities, including developed world settings. How often the controls were washing under their foreskins is not clear, but it is hard to imagine they were all neglecting to do so. There is even a study which found that the microbiome of the man’s penis predicts that of his female partner’s genitals (Mehta et al., 2020). This provides a mechanism to explain the findings of a RCT which found that the female partners of circumcised men are less prone to bacterial vaginosis, genital ulceration and Trichomonas infection (Gray et al., 2009). Being circumcised really is cleaner after all.
Urinary tract infections. One only has to get to the third sentence of this section to find a misleading statement: “overall UTIs are much more common in females and males” but the citation he gives is for urinary tract infections (UTIs) in males > 13 years old. In the neonatal period, and in premature infants, UTIs are much more common in males (Arshad & Seed, 2015) and it is in this period that the risk of renal damage, other complications, and death are greatest. In fact, prior to the advent of antibiotics, UTIs accounted for up to 20% of infant mortality (Zorc et al., 2005a). Because the evidence that circumcision is highly protective against UTIs, with numerous studies confirming it, even Meddings concedes this, but seeks to explain them away with spurious arguments. Thus, says Meddings, parents are not bathing their babies properly, or they are forcibly retracting their foreskins, but he provides no evidence. The only counterclaim he does try to support with citations is an assertion that maybe the apparent protective effect is because urine samples from uncircumcised boys are contaminated. Aside from this being a tacit admission that the space under their foreskins is a reservoir for bacteria (hence the proneness to UTIs), this issue is well known, as attested to by Meddings’ own citation (no. 71). When already febrile (and hence obviously infected) male infants had their urine collected by catheter (thereby avoiding contamination), those with foreskins were 9 times more likely to have a UTI (Zorc et al., 2005b). Thus, the protective effect of circumcision is real.
Meddings’ complaints about benefits not outweighing the risks, or circumcision not being cost-effective for UTIs, overlook the fact that (outside of high-HIV settings) the case for infant circumcision is not predicated on any one single benefit, but on all of them added together. Thus, his complaints that circumcision fails risk or cost/benefit ratios for UTIs in isolation are examples of the straw man fallacy. Finally, before leaving this subsection, attention must be drawn to Meddings’ flippant remark that “UTIs are usually easily treated with antibiotics”. Aside from rampant antibiotic resistance, which further antibiotic use will only make worse, and with most UTIs now showing resistance to front-line antibiotics in some countries (Bryce et al., 2016), there is nothing “easy” about intravenous (IV) antibiotics. Having twice had my life, or at least a limb, saved by them, I should know. They are not pleasant. And for infants they must be IV, as oral ones are difficult to administer, and adsorption is poor. Hospital admission is required. Infant UTIs and the treatments for them are painful, traumatic, and costly. Prevention is better than cure!
Sexually transmissible infections. That Meddings opens with a weak, indeed arguably discredited, study does not bode well. He cites a study by Danish circumcision opponents Frisch & Simonsen (2022) purporting to find that circumcised men have higher rates of certain STIs but ignores the severe criticisms their paper attracted from two independent teams. Now, as these were very recently published, I’ll be charitable to Meddings, and assume they simply were not available at the time he wrote his book, although I suspect that even if they were he would have ignored them anyway. That being normal behaviour for circumcision opponents. The first critique was a letter by fellow Danes and one non-Dane (Meyrowitsch et al., 2022). They pointed out that Frisch & Simonsen (F&S) could not separate from their data set men who have sex with men (MSM). This matters enormously as they have far higher rates of STIs, and circumcision makes little difference if infection occurs via receptive anal intercourse. F&S’s argument also lacked biological plausibility. F&S responded with a straw man argument that circumcision does not correlate with sexual orientation. True, but irrelevant. As circumcision confers little benefit for MSM (there is a modest benefit for the active, i.e., insertive, participant in anal sex, but not the passive one for whom most of the risk applies), it follows that inclusion of MSM in a study will fail to address any protective effect of being circumcised for heterosexual sex, and any such effect may be obscured. The same criticisms were later made by Morris et al. (2022), who also pointed out numerical instability in the statistics, failure to distinguish different types of HPV and, perhaps most significantly, failure to exclude non-ethic Danes. In fact, almost the entire circumcised cohort were of non-Danish ethnicity. So, all F&S were measuring was the effect of ethnicity on STIs, not circumcision! In so doing they merely confirmed what was already known from multiple other studies – that ethnic minorities often have higher rates of STIs than their host populations.
Other shaky arguments Meddings employs in this subsection are that a condom is still needed, that it is “bizarre logic” to apply circumcision to “sexually immature children” (but previously he was OK about giving HPV vaccine to the same) and that there are better methods of prevention (e.g. condoms). These are familiar arguments, and are answered here https://circfacts.org/general-information/#med1 and here https://circfacts.org/general-information/#med2. Like circumcision, none of the alternatives is 100% effective. Using every tool one has, including circumcision, maximizes protection. Would Meddings dispense with air bags in a car just because he can wear a seatbelt? Finally, before moving on, Morris et al., (2022) list 23 studies, in developing and developed countries alike, looking only at infant and child circumcision, nearly all found a protective affect against a range of STIs (though not all). This is in addition to studies on adults in RCTs, cohort and case control studies finding the same. Generally, circumcision provides partial protection against viral and ulcerative STIs, although, as one would predict, not urethral ones such as gonorrhoea and chlamydia.
Male circumcision and HIV “prevention”. Meddings concludes Chapter 3 with a lengthy section on HIV, and the distortions become particularly egregious, as we shall see. Circumcision is effective at reducing female to male transmission, but not vice versa, as he correctly states. It is of little benefit for MSM, as explained earlier.
Page 38: He states “the argument that it provides a partial protective effect for men rests to some degree on several observational studies”, but cites just two. His claim massively downplays the large body of evidence that had accumulated prior to the three famous RCTs that clinched it. By 2000, there were at least 33 studies, meta-analysis of which found a pronounced protective effect (O’Farrell & Egger, 2000), and that was still half a dozen years before the RCTs were published. But it is the RCTs which settled the matter in the eyes of all, except ideologues committed to the dogma that circumcision has no benefits, so it is these that Meddings focuses on.
When the three RCTs were published (Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007) they attracted a storm of criticism from intactivists, but those criticisms were all thoroughly debunked to the satisfaction of the WHO, CDC, PEPFAR, UNAIDS, Gates Foundation … indeed every professional body dealing with the epidemic. For a summary of the articles attacking the RCTs, and the replies debunking them see https://circfacts.org/medical-benefits/hivaids/. Predictably, Meddings relies on the intactivist articles and totally ignores the debunkings, as he trots out a succession of discredited claims. Thus:
Page 39: He says the RCTs suffered from “researcher expectation bias, selection bias, participant expectation bias, lead-time bias, duration bias, attrition bias, and early termination bias” citing the notoriously unreliable intactivist Van Howe and his wife, Storms (2011). For more on Van Howe see https://circfacts.org/blog/#blog2. Predictably, Meddings totally ignores the detailed, point-by-point rebuttal that followed by a group of experts including some who were involved in the RCTs (Morris et al., 2011). So, the reader is left with no indication that the supposed biases are variously, irrelevant, baseless opinions, or just plain false. An additional debunking of the “lead-time bias” fiction is here: https://circfacts.org/medical-benefits/hivaids/#hiv6, noting that it is an intactivist favourite.
Page 39: Next he claims that the results of the RCTs “cannot be extrapolated beyond sub-Saharan Africa”. Why not? All indications are that the effect is causal, with clear evidence of causality (Byakika-Tusiime, 2008). Multiple mechanisms have been identified, the common feature being the foreskin. The foreskin mucosa is a weak point that lets the virus into the bloodstream via HIV receptors (Morris and Wamai, 2012; Rasheed, 2018). As the effect is biological, it will not matter where in the world the foreskin is located. Removing it will provide partial protection against heterosexually acquired HIV whether the man is in Africa or Antarctica. The only difference geography will make is to influence how much the man needs that extra protection (there are probably not many opportunities to contract HIV in Antarctica).
Page 39: He states, “All three RCTs assumed their participants to be heterosexual”. As the trials specifically concerned heterosexual transmission, is it unlikely homosexuals would have been interested in participating, aside from the severe suppression of homosexuality in the countries concerned (which Meddings admits). Meddings also seems not to understand the strength of the RCT study design. Control and intervention groups were selected randomly, so any MSM who got involved will have been equally distributed between the two groups, thereby cancelling out any influence they might have had on the results. The same is true for heterosexual men having anal sex with women. In a footnote on page 1 of Morris et al. (2022) it is explained that the researchers in the Kenyan and Ugandan trials had already determined that homosexual sex was “extremely rare” in their study populations.
Page 40: Meddings complains about the drop-out (attrition) rate, again without understanding that because the drop-out rate was similar for both groups drop-out did not matter. As pointed out in another rebuttal (which Meddings ignores, as usual), “Each trial achieved over 90% of their expected study visits, and there was no evidence that those with incomplete follow-up had a different risk profile” (Wamai et al., 2008).
Page 41: Meddings proceeds to another intactivist favourite – fixating on absolute rather than relative risk reduction. The RCTs showed that circumcision reduces the chances of the man contracting HIV heterosexually by about 60% (actually, it is around 70%, as shown by later work, but I digress). That value is the relative risk reduction. But the absolute value (a function of the actual numbers of men protected during the study period) is much lower. Meddings cites 1.31%, a number first conjured up by Van Howe in an unpublished work, but then copied by other intactivists (although Meddings does not disclose this). This number is simultaneously wrong, and excellent. Wrong because the correct value is actually 1.8%, as derived in a Cochrane Review, a far more credible source than Meddings (or Van Howe) (Siegfried et al., 2009). But, for the sake of argument, we’ll stick with 1.31%. That was for the two years of the study period so, after 20 years it will be 13.1% which, in a population of a million sexually active males is 131,000 new infections averted. Extrapolate across all of sub-Saharan Africa and extend to the end of the century and easily it translates into tens or hundreds of millions of infections averted. That’s excellent!
The argument is examined in more detail here: https://circfacts.org/medical-benefits/hivaids/#hiv10 and was also debunked in print by Morris et al. (2016) which, naturally, Meddings ignores. But the problem does not end there. Meddings supports vaccination (page 107) yet disparages an absolute risk reduction of 1.3%. I wonder what he thinks, then, of the AstraZeneca COVID-19 vaccine which also has an absolute risk reduction of 1.3%? Or the Moderna vaccine (1.2%)? Or the Gamaleya vaccine (0.93%)? Or Pfizer’s vaccine (0.84%)? (Olliaro et al., 2021). Anti-vaxxers love those numbers because they know they can bamboozle people with them as most laypeople are unfamiliar with medical statistical terms like “absolute” vs “relative” risk reduction, do not know when to use one and not the other, and do not realise that 1.3% is actually very good, cumulative over time, and translates into huge numbers of infections averted when applied at the population level. But Meddings does know – he has a relevant background, and he defines the terms in his text. So, he knows he is being misleading. The expression “lying with statistics” comes to mind.
At this point I was tempted to just give up, the smell of male bovine excrement was becoming overpowering, but with just a few pages to go to the end of the chapter I decided to battle on till then. But the smell only got worse!
Page 41: “Perhaps cutting away the mucosal tissue of young girl’s genitals could reduce HIV transmission”, but thankfully such a study would not be allowed ethically, he says. Fortunately, such a study is unnecessary as there is enough research on countries where FGM is practiced indicating that there is likely no effect, or even an increased risk (Pinheiro, 2019).
Page 42: After repeating the false assertion that the RCT findings cannot be applied to the developed world, Meddings then cites a Canadian study in which, he claims, “circumcision was not associated with the risk of men acquiring HIV”, while ignoring, as usual, the critique which pointed out that the authors of this study failed to exclude MSM. When MSM were taken into account then the (previously non-significant) protective effect the authors detected was found to actually be about what one would expect (Morris & Krieger, 2022). The Canadian authors agreed with the latter calculations in stating that “lack of consideration of sexual orientation and potential risk behavior differences” were limitations of their study (Nayan et al., 2022).
Page 42: Meddings whines about basing policy on the RCTs “despite their many flaws and limitations”, but, as we have seen, the purported “flaws and limitations” are just figments of the imaginations of denialists whose dogmatic opposition to circumcision blinds them to the evidence. Contrary to Meddings’ falsehoods, the African circumcision program is “based on mountains of mutually supportive medical evidence”. We have seen that there were already almost three dozen observational studies by 2000 finding a protective effect (more have been published since). We have seen that mechanisms have been identified, the effect is causative, and biological in nature. On top of all that, we now also have real world data showing that where circumcision is being rolled out HIV incidence is falling (Auvert et al., 2013; McGillen, et al., 2019; Loevensohn et al., 2021; Korenromp et al, 2021; Johnson et al, 2022; Santelli et al, 2022; Masango et al, 2013), and falling faster in men than in women as it is men who are directly protected (Kong et al., 2016; Grabowski et al., 2017; Vandormael, et al., 2019; Vandormael et al., 2020). In short, it is working! This is about as good as it gets in medical science. Tens of observational studies, three RCTs, a series of meta-analyses (not all cited here), the mechanisms identified, and real-world data showing that the procedure works. And still there are people like Meddings who remain firmly stuck in denial.
Page 43: The garbage continues with a reference to Wawer et al. (2009) which Meddings misinterprets and misrepresents. The effect (increased risk to women if their recently circumcised partner was HIV positive) was barely significant, and it happened only because some men resumed sex before their circumcision had fully healed. And his claim that this increase is why the study was terminated early is just plain wrong. It is also insulting as it casts baseless aspersions on the integrity of the researchers. Which, in turn, is hypocritical, as by now it should be glaringly obvious that it is Meddings’ integrity that should be in doubt. In fact, their sample size was too small to allow meaningful statistical analysis, so it was considered futile to continue, as explained by the authors, and again by Weiss et al. (2009), which, naturally, Meddings ignores. He even has the gall to conclude this part by accusing those who recommend circumcision in the context of African HIV as being “reckless and irresponsible in the extreme”. But one might rightly ask if undermining with pseudoscience and discredited arguments one of the most effective weapons against African HIV is irresponsible! The hypocrisy is breathtaking. For more detail on how intactivists misuse this study see: https://circfacts.org/medical-benefits/hivaids/#hiv8.
Page 43: Meddings touts condoms, and pre- and post-exposure prophylaxis (PrEP and PEP) as alternatives, but these all have shortcomings, as explained here (for condoms): https://circfacts.org/general-information/#med1. And he persists in his falsehood that the 1.31% absolute risk reduction is “trivial”. Like the AstraZeneca COVID-19 vaccine? He just does not “get it”. There is no 100% effective prophylaxis against HIV transmission. However, medical circumcision is recognised as one of the three best, the others being condoms (which are, at best, only partially effective) and anti-retroviral therapy (ART, which requires the person to have already been infected with HIV) (Grabowski et al. 2017; Johnson et al., 2022; WHO, 2016).
Page 44: After repeating his falsehoods about risk reduction, the wonders of condoms, PrEP, and supposedly desensitized circumcised men shunning condoms, Meddings comes to that other popular intactivist myth: risk compensation. His prelude states “it is possible circumcised men may be less likely to use a condom given that their penises are desensitised as a result, or if they are under the impression their circumcised status provides them adequate protection, as media reports in Africa indicate many men are” (citing a news media report).
Instead of citing a media report, why did he not cite peer-reviewed science where possible? There is an enormous literature on the behaviour of men (and their female partners) following circumcision. And some studies do, indeed, find indications that a few dispense with condoms following the procedure. But most don’t. Essentially, providing they are properly educated, understand that circumcision is only partially protective, and they should still practice safe sex, men (and women) do behave responsibly. There is now a large systematic review and meta-analysis confirming that this is not a problem (Gao et al., 2021). Unsurprisingly, Meddings ignores this. There is also an element of hypocrisy in the argument as, in principle, any of the interventions Meddings offers as alternatives to circumcision could have the same effect. Men using condoms might think they can be as promiscuous as they want. Those using ART, PrEP or PEP might dispense with condoms. The argument is an argument for education, not against circumcision (or condoms etc.).
Page 45: On the final page of this tedious Gish gallop of nonsense, Meddings cites the late Robert Darby’s 2014 article on the history of circumcision with respect to syphilis but, true to form, ignores the rebuttal it attracted (Morris et al., 2015). He concludes with the accusation that promoting circumcision in Africa is “cultural imperialism”, citing Fish et al. (2020). Again, ignoring the critique that followed (Morris, 2021). Amongst other things, Fish et al. tried to compare the African circumcision program with the infamous Tuskegee experiment. The same comparison is also used by anti-vaxxers, who also like to play the race card (CCDH, 2020). As we saw with the absolute risk reduction argument, there is overlap between anti-vaxxers and their ugly sisters the intactivists.
ENOUGH! I spent much of my Christmas/New Year holiday period writing this, and still there are seven more chapters to go. But it is not necessary to debunk them all to show that Meddings cannot be trusted, and I have not the time. The above is more than ample to show that Meddings is thoroughly biased and unreliable on this topic. His literature citations are cherry-picked, debunkings are routinely ignored, half-truths, misleading claims and outright falsehoods abound. And his logic is sloppy, displaying a particular fondness for false analogies and emotive language.
His book is being actively touted by intactivists. It will mislead, misinform, and misdirect its readers. Circumcised men will be left thinking, wrongly, that they are missing something wonderful, causing them needless distress. Those who happen to have a sexual problem could be duped into blaming it on their circumcision instead of whatever is the real cause. Parents who have had a son circumcised might suffer unnecessary guilt. Men and boys suffering a medical problem that a circumcision would relieve may be deterred from seeking the procedure they need. And if it is read by those in countries blighted by HIV, they may be deterred from availing themselves of the procedure, thereby putting themselves and their partners at increased risk. Thus Meddings could be responsible for avoidable suffering and deaths. It is not promoters of the procedure who are being “reckless and irresponsible in the extreme”. It is Jonathan Meddings.
REFERENCES & NOTES
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Meyrowitsch, D., Andersen, L.S., Lohse, N., Euler-Chelpin, M. von, Hankins, C. (2022) Re: Frisch & Simonsen. Non-therapuetic male circumcision in infancy or childhood and risk of human immunodeficiency virus and other sexually transmitted infections: national cohort study in Denmark. European Journal of Epidemiology, 37, 651-652. https://link.springer.com/article/10.1007/s10654-022-00872-7 Frisch & Simonsen’s response follows on p. 653-4.
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Morris, B.J., Wamai, R.G., Krieger, J.N., Banerjee, J., Klausner, J.D. (2015) Male circumcision to prevent syphilis in 1855 and HIV in 1996 is supported by the accumulated evidence to 2015: Response to Darby. Global Public Health, 12(10), 1315-1333. https://pubmed.ncbi.nlm.nih.gov/26564989/
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Morris, B.J. (2021) Voluntary medical male circumcision proves robust for mitigating heterosexual human immunodeficiency infection. Clinical Infectious Diseases, 73(7), e1954-e1956. https://pubmed.ncbi.nlm.nih.gov/33043971/ Note: this contained some trivial errors – the name of the lead author, Max Fish, her profession, and the name of her organisation opposing circumcision, were incorrect, as she and co-authors pointed out, leading to an erratum. But the technical arguments were sound and largely ignored by Fish et al.
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