Only One Fact Is True for the Individual Child

In an entry titled “The Facts As Promised“, Lauren at Can You Be A Part of My Life fails to consider the context of her selected (and occasionally incorrect) facts about infant circumcision. I expected little going in because she opened with her attributions. Among her three sources were the websites of Professor Brian Morris and Dr. Edgar Schoen. It would be difficult to find a greater propagandist than either of those two.

Throw that truth out, though. Where they are correct with statistics, they ignore the most important fact present in almost every case where they advocate infant male circumcision, which Lauren readily ignores along with them: the child is normal and healthy. No surgery is indicated. There is no need to weigh against the inevitable risks. That is the only proper evidence-based analysis. One need not reject any of the statistics claimed to understand that the individual does not require circumcision. Circumcision by parental proxy is therefore unjustifiable.

But the claims merit a response. Here is an excerpt from the first paragraph of substance on circumcision in Lauren’s entry:

… And it is MUCH harder to keep this area clean in infant babies for various reason and therefore leads to: a higher risk of death in the first year of life (from complications of urinary tract infections: viz. kidney failure, meningitis and infection of bone marrow).

WebMD, a site that generally endorses unnecessary infant circumcision, states this about the normal infant foreskin, with emphasis in the original:

Do not force the foreskin back over the tip of the penis. At first, a baby’s foreskin may be difficult to pull back over the tip of the penis. After the first few years of life (though it may take somewhat longer), the foreskin will gradually become more retractable. By the time a boy is age 3, his foreskin is usually fully retractable. Up to this time, wash the outside of the penis with soap and water. Pushing your son’s foreskin back too early can cause scar tissue formation and damage.

Is washing the intact penis that MUCH harder to keep clean than the circumcised penis? Considering the process is identical, it’s clearly not MUCH harder. Pretending otherwise is misinformation. It is also worth remembering that circumcision creates an open wound that must be cared for properly to avoid infection and readhesion. This makes care for the circumcised penis more complicated for parents than properly caring for the normal penis.

Here I’d like to add a special caveat. If you don’t wish to care for normal, healthy children, don’t reproduce. Otherwise, the proper care of your normal, healthy children is an obligation, not a chore to be discarded in reverence to fear and mistaken beliefs.

For the the remainder of this entry, I’ll take the issues point-by-point. However, I want to make it clear that from this point forward, I’m challenging the claims of Professor Brian Morris. The bulk of Lauren’s entry involves only a copy-and-paste from Morris’ site. Lauren (wisely) provided some editorial input, omitting several absurdly irrelevant claims proffered by Morris. Of course, those should be considered to fully understand his judgment in pushing the other claims over the objective reality of health for most infant males. “A penis that is regarded by most as being more attractive” is not an indication of medical necessity. It’s a sign of an ability to think only collectively, to not understand that all tastes and preferences are subjective and individual. That is flawed because it ignores ethics and human rights.

So, addressing Professor Morris’ claims. (Link is here: http://www.circinfo.net/summary.html) Under the section titled “The benefits are clear” from Lauren’s entry, this list from Morris titled “Getting circumcised will result in”:

• Improved hygiene.

This is misleading, at best. See my comments above on this.

• Much lower risk of urinary tract infections.

The risk is lower, by a factor of approximately 10. However, the risk is already very low. More on this in a moment. (Note: The risk for girls is also approximately 3 times higher than it is for intact boys. We treat UTIs in infant girls if/when they appear.)

• Much lower chance of acquiring AIDS heterosexually.

Condoms and monogamy or condoms, monogamy, and circumcision. Those are the two choices. Circumcision is superfluous. Unprotected sex with HIV-infected partners will lead to infection. Circumcision has not helped me avoid HIV infection because I do not behave irresponsibly. Had my parents used this excuse, it would’ve been misguided. Parents are not Nostradamus.

Notice, too, how easily this omits the fact that the studies were performed on adult volunteers, not infants. Surgery is different technically and ethically for the two patient groups. The infant foreskin must be forcibly retracted. Infants aren’t sexaully active.

• Virtually complete elimination of the risk of invasive penile cancer.

The risk of penile cancer is small, regardless of foreskin status. From the 1999 AAP statement on infant circumcision, the risk of penile cancer varies little among Western nations. It is generally around 1 per 100,000 males. Other risk factors appear to be more significant. The consensus seems to be that, circumcised or not, healthy, responsible living is the best way to protect against such illnesses.

For context, there were 1,250 new cases of penile cancer in America in 2008 and 290 deaths. There were an estimated 1,990 cases of invasive breast cancer in American men in 2008, including 450 deaths. Time to panic and remove infant male breast tissue? The logic would be the same.

• More favourable hygiene for the man’s sexual partner.

This can be read as either a claim that women prefer a circumcised penis because it is cleaner or that it improves female hygiene. I’ve already dismissed the former claim, and Lauren correctly points out the absurdity of suggesting that adult males are incapable of cleaning their foreskins. The latter claim would tie in to the next bullet point.

• Much lower risk of cervical cancer and Chlamydia (and thus infertility and other problems) in the female sexual partner.

The ethical questions aside, there is a vaccine for HPV. That aside, as it relates to the foreskin, personal responsibility among the sexual pair matters: “In men with low-risk sexual behaviour and monogamous female partners, circumcision makes no difference to the risk of cervical cancer.” It is flawed to assume at birth that the male will be promiscuous. It is also flawed to assume that it’s ethical to surgically alter one person to protect his potential sexual partners. For example, what if he is gay?

• More favorable sexual function and no reduction in sensation during arousal or in the sensitivity of the flaccid penis.

Circumcision clearly alters sexual intercourse. Whether or not that is “more favorable” – a subjective evaluation – can only legitimately be determined by the individual himself. The foreskin contains thousands of nerve endings. Again, removing those alters sexual intercourse. Whether or not
that reduces sensation is impossible to compare once the foreskin is removed. Only the male himself is qualified to make that decision.

Now, to Morris’ claims under “lack of circumcision” linked in Lauren’s entry. He states:

Is responsible for a 12-fold higher risk of urinary tract infections in infancy. Risk = 1 in 20. Higher risk of UTI at older ages as well.

He provides no source for his claim of a 12-fold higher risk. I assume he’s pulling this from a study by Thomas Wiswell, but I’m guessing, since he didn’t source it. I have no idea where he found the risk to be 1 in 20. According to the more recent statement from the AAP, estimates are “that 10 of 1000 (1%) uncircumcised male infants will develop a UTI during the first year of life compared with 1 of 1000 (0.1%) circumcised male infants.” Claims like “12-fold higher risk” don’t look quite as compelling when considered in context. Also, females in the first year of life have a risk of UTIs equal-to or higher-than intact males. We treat those without surgery, even after they actually occur.

Confers a higher risk of death in the first year of life (from complications of urinary tract infections: viz. kidney failure, meningitis and infection of bone marrow).

I addressed this above with the hygiene issue, so here I’ll take a different approach. What is that risk of death? Professor Morris does not state the risk, nor does he link to a source for his claim. I have no problem accepting that it’s true, but are we debating a 50% risk of death from the foreskin? A 25% risk? Or are we discussing a risk significantly lower than 1%? I would wager the third option is closest to the truth. Ultimately life has risks. We can’t live in bubbles to prevent bad things from happening, particularly when those bad things are very unlikely.

One in ~400-900 uncircumcised men will get cancer of the penis, which is over 20 times higher in uncircumcised men. A quarter of these will die from it and the rest will require complete or partial penile amputation as a result. (In contrast, invasive penile cancer never occurs or is extraordinarily rare in men circumcised at birth.) (Data from studies in the USA, Denmark and Australia, which are not to be confused with the often quoted, but misleading, annual incidence figures of 1 in 100,000).

The often-quoted figures are quoted by the AAP. I’m willing to consider that it’s misquoted, and I’ll correct if it is. But Morris does not show here how this statistic is misused. He merely attempts to scare us with a few numbers that are not impressive in the context of actual population sizes and risk factors. He expects the reader to accept his cost-benefit analysis, weighing the 400-900 and 200 against the 1,000,000+ infant males circumcised to achieve these results. I do not because we are discussing surgery on individuals, not groups. Actual human beings, with opinions, preferences, and needs are involved. I refuse to behave like an irrational collectivist.

Is associated with 3-fold higher risk of inflammation and infection of the skin of the penis. This includes balanitis (inflammation of the glans), posthitis (inflammation of the foreskin), phimosis (inability to retract the foreskin) and paraphimosis (constriction of the penis by a tight foreskin). Up to 18% of uncircumcised boys will develop one of these by 8 years of age, whereas all are unknown in the circumcised. Risk of balanoposthitis = 1 in 6. Obstruction to urine flow = 1 in 10-50. Risk of these is even higher in diabetic men.

Balanitis

Balanitis is easily treated. Practising good hygiene and avoiding substances that irritate the penis will often clear the balanitis. (See the Treatment section for more information).

The rest…:

Phimosis

Phimosis is when the foreskin is very tight and cannot be pulled back over the head of the penis (glans). It’s normal for the foreskin to be attached to the head of the penis up until about age five. Parents should not try to pull the foreskin back because it can cause pain or injury. However, after the age of five, the foreskin will usually separate by itself and can be pulled back.

In some boys, phimosis can continue up to the age of 10 and, occasionally, it can continue into adulthood. Boys who have phimosis, and are under the age of six, do not usually require circumcision, but it may be considered after this age if the foreskin is damaged. Damage can happen as a result of severe or repeated infections. However, in the majority of cases, the foreskin will loosen naturally, with true phimosis (see below) only accounting for about 1% of cases.
…

Paraphimosis

Paraphimosis is a tight foreskin that cannot be pulled back, meaning the penis is squeezed, which causes pain. It forms a ring around the penis, cutting off some of the blood flow to the glans, and making it swell up. Doctors can sometimes treat paraphimosis by gently squeezing the trapped glans until the foreskin is able to slide over it. However, if this is not possible, circumcision may be needed.

I do not deny that risks exist, and that maladies occur. These conditions indicate a legitimate need for medical treatment. If parents must make a decision here, so be it. But the clear evidence is that these can – and therefore should – be treated with methods less invasive than circumcision, if possible. That is the reasonable medical approach to a permanent, irreversible decision.

Means increased risk of problems that may necessitate 1 in 10 older children and men requiring circumcision later in life, when the cost is 10 times higher the procedure is less convenient, and the cosmetic result can be not as good as when done in infancy.

Morris would circumcise 10 in 10 male infants to avoid circumcising 1 in 10 males later in life. He states that the cost is 10 times higher. The overall financial burden to society is unchanged, contrary to what he’s trying to convey through fear. (Future financial burden is not a valid reason to circumcise a healthy child.)

Speaking strictly from a finance perspective, advocating for infant circumcision is the more expensive approach. His analysis is that the cost is 10 times 0.1 for his preference and 0.1 times 10 for his worst case. The present value of $1 spent over many years in the future is less than the $1 spent today. Professor Morris prefers the more expensive option.

Nor should convenience be considered. That is not a medical indication. If the male wishes circumcision more than the inconvenience, he will choose it. If not, it is not acceptable for parents to choose that for him, against his (probable, based on statistics) future choice.

As for cosmetic results, this is simply insane. Circumcising an infant places the parents’ aesthetic sexual preference as the justification, even though the child may not choose it. He gets zero choice, and the cosmetic results aren’t guaranteed to be good by whatever future subjective standards he develops. If he is left with his decision, he can decide if he values the risk of a poor cosmetic outcome versus his normal penis.

Increases by 2-4 fold the risk of thrush and sexually transmitted infections such as human papillomavirus (HPV), syphilis, chancroid and, in some studies Chlamydia.

And:

Is the biggest risk factor for heterosexually-acquired AIDS virus infection in men. 3 to 8-times higher risk by itself, and even higher when lesions from STIs are added in. Risk per exposure = 1 in 300.

And:

In the female partners of uncircumcised men is
associated with a 5 fold higher incidence of cervical cancer (caused by sexually transmitted HPV), pelvic inflammatory disease, infertility from blockage of fallopian tubes, extopic pregnancy (each caused by Chlamydia), genital herpes, and other conditions.

Condoms and monogamy are necessary, regardless. Forcing circumcision on sexually-inactive infant males does not change the necessity of practicing safe sex when they become sexually active. At its core, this is merely a belief that males will be irresponsible and/or female health is more important than a male’s normal body. It also assumes that his future female (or male?) partners will not be responsible enough to protect themselves from STDs.

The core evaluation is very simple. If the child is healthy, no surgery is indicated or justifiable. Chasing benefits for children is an illogical path that can be pursued to other irrational avenues and on both genders. It has no place in the proxy decision-making of parents for the genitals of their male children, as we already understand clearly for female children.

UPDATE: I corrected one point of grammar and added the word males to “1 in 10” for clarification. I also added if possible to my statement that less invasive treatments should be used to treat foreskin ailments. Circumcision is sometimes necessary, of course, but it should be used as the last option, not the first.