Why circumcision is a very good thing

I’ve written numerous posts about circumcision and its benefits, but I want to write one more big one. My goal here is to gather together all the relevant information to the debate in one place. Certain myths need to be dispelled in some places while the details of arguments need to be laid out with ridiculous clarity; the anti-circumcision crowd is as stubborn as young Earth creationists. As such, this post isn’t so much directed towards the entrenched anti-circumcision folk as it is towards the people on the fence. Perhaps there are a few people out there who have simply bought into easy arguments, and so their commitment to their position can be swayed. I would equate these people with the occasional church patron that grows up learning the Universe is 6,000 years old, only to later shed that false belief when engaged on the matter. I hope I’m able to adequately mount a defense of circumcision and change the minds of any such people who end up reading this post.

There are several topics that should be addressed when discussing circumcision. Safety, efficacy, and ethics are the broad categories, and each one contains its share of details. Let’s start with safety.

Safety:

As with any surgery, complications are possible. The most common complication due to circumcision is minor bleeding, which can be fixed with a little bit of gauze. Infections occasionally happen, but they’re rare. Circumcision should always be done under sterile conditions to maintain this rarity. (That means the Rabbis and other non-medical professionals out there who do these things need to be stopped.)

Pain and Trauma:

A favorite of the anti-circumcision crowd is to find awful looking restraining devices doctors use to keep infants steady. Aside from the fact that those devices aren’t the iron maidens people make them out to be, circumcision needn’t be painful in the least. Any search will find a mix of estimates for how frequently anesthesia is used during circumcisions, but it is certainly used a majority of the time, and its use is always increasing. Any parent worried about the pain their baby may feel can simply request anesthesia be used. This 100% addresses any pain argument the anti-circumcision crowd wants to raise. Indeed, it also addresses any trauma argument they wish to raise, but it isn’t necessary for that purpose. Trauma is something which has lasting physical or psychological damage. Since no infant can possibly remember being circumcised, there’s no way any amount of pain could be traumatic here. Moreover, the pain of being squeezed through a vaginal canal just days earlier is clearly much more significant than any minor medical procedure.

Nerve Ending Hypothesis:

There is a popular hypothesis that because the foreskin has 10,000 to 20,000 nerve endings, any removal of it must affect sensitivity. It makes sense and it’s worth investigating. Unfortunately, it’s that investigation aspect that many in the anti-circumcision crowd don’t like; for many, the hypothesis is conclusive. Occasionally, though, they may point to a study or two they incidentally find – so long as it supports their beliefs, of course. These studies (which are usually actually just subjective surveys) sometimes indicate decreased sensitivity in circumcised men. Other times, they show just the opposite. (The anti-circumcision crowd ignores those.) Mostly, though, they show statistically insignificant differences. Moreover, the better studies and meta-analyses out there show the same wash. Since science operates on bodies of evidence rather than individual studies – if you can’t repeat your data, it’s bullshit – the correct conclusion here is that not only is there no body of evidence that circumcision decreases sensitivity, but there is actually an active body of evidence which shows it has no effect.

Efficacy:

This is where the majority of this debate centers. It isn’t enough to look at all the evidence and conclude that circumcision is low-risk, painless, non-traumatic, and inconsequential in sexual sensitivity and performance. That’s all great, but none of that adds up to a reason to circumcise someone, much less to implement it as a public health policy. What we need is data which show circumcision offers some sort of benefit. You’ll never guess what we’ve had for the better part of a decade.

Three randomized control studies were undertaken and completed between 2005 and 2007. These studies looked at the effect of circumcision on HIV transmission rates from women to men during heterosexual intercourse. (Prior to these studies there was a body of observational studies which indicated a likely link between circumcision and HIV, but it wasn’t nearly concrete enough to enact any type of policy.) These studies concluded that circumcision significantly reduces HIV transmission in the aforementioned context; one study went so far as to compare the reduction to what would be achieved by “a vaccine of high efficacy”. Between the studies, the relative risk reduction was 60%.

Relative versus Absolute

For some time I had an anti-circumcision troll around here. He enjoyed raising the issue of relative risk versus absolute risk. I’m not sure he understood the difference, though. Whereas the relative risk reduction for circumcised males was found to be 60%, the absolute risk reduction is between 1.3% and 1.8%. Choosing the latter of these numbers is a good way to muddle the discussion. Here’s what these numbers mean.

Relative risk reduction is how much a given treatment, behavior, or characteristic reduces a given risk in one group versus another. This is the number that matters most of the time in lay terms. Absolute risk reduction, on the other hand, looks at an entire population and takes into account its susceptibility to some given condition. For instance, most people aren’t going to get the flu. It doesn’t matter whether a person has the vaccine or not. Odds are low that he or she will catch anything. That’s why anti-vaccine quacks love to use absolute numbers. The flu vaccine is generally somewhere near 60% effective, but absolute numbers are closer to 1.5%. That isn’t an argument against getting vaccinated, though.

Problems with the Studies

The three aforementioned studies were robust and have been largely accepted by the scientific community. The WHO, UNAIDS, the CDC, the Bill and Melinda Gates Foundation, and a dozen and a half African health ministries have all embraced their results. Of course, that isn’t going to stop the anti-circumcision crowd from coming up with something to question. Most commonly, the issues raised are non-issues. For instance, I’ve frequently seen the point raised that condoms are more effective. This is like when a creationist tries to argue against evolution by talking about the Big Bang. It just isn’t on topic. Other issues include the region where the studies took place, the early termination of the studies, and control and intervention groups being treated differently. Let’s start with where these studies took place.

It should first be noted that, as I mentioned earlier, there is a large body of observational studies on the effectiveness of circumcision in HIV transmission reduction. This body is global; what it indicated panned out in these trials. Second, Africa is massive. Uganda and Kenya are neighbors, but South Africa isn’t even close. These places have commonalities, but they are also significantly different in a host of aspects, including culturally. Repeated results across a wide swath of area cannot be simply dismissed out of hand: the limited region of each individual study could be a confounding factor, but when taken as a whole, the studies necessarily reduce any potential confounding factor due to regional affect.

Each study was halted early on ethical grounds. The results were so overwhelming, the monitoring boards for each study had no choice but to put an end to the trials and recommend that all the uncircumcised men be circumcised. Regardless, the studies still all lasted between about a year and a half and two years. Potential bias as a result of these abrupt endings were taken into account. From the Kenya study:

Because the Data and Safety Monitoring Board recommended to stop the trial after the intermediate analysis, it was not possible to follow all the participants as initially planned, and, as a consequence, only those participants recruited at the beginning had a full follow-up. This potential bias was taken into account by adjusting the analysis for the recruitment period; such an adjustment cannot fully account for the confounding effect associated with partial follow-up. When restricting the analysis to those participants who had a full follow-up, the intervention had an effect that was similar in size and significance, suggesting that this potential bias had a negligible impact.

Another common complaint is that a large number of participant follow-ups were lost due to the early terminations. The effect was likely negligible since the numbers actually weren’t that significant for these type of studies, plus many of the follow-ups were actually lost for reasons unrelated to HIV infection (such as moving from the area). Knowing this is one of the benefits of having actually read the studies rather than agenda-driven websites.

Finally, I frequently come across Internet comments that declare the control and intervention group were treated differently. The claim is that the intervention (circumcised) group was given education, condoms, and counseling over and above what the control group was given. This is simply a lie. I’m not sure of its origin, but I’ve seen it enough that I feel it deserves to be killed. The groups were given and/or offered consistent treatment. The only reason to say otherwise is for the same reason Lyndon Johnson told one of his aides to spread the story that one of his opponents fornicated with pigs. He knew it wasn’t true, but if he could make the other guy deny it, he would be giving it credence by simply addressing it. As usual, I’m willing to forgo the public perception in favor of assuming a literate readership.

How It Works

The evidence is in when it comes to circumcision, but how it works is still up for question. One hypothesis says that the foreskin offers a relatively damp environment that is friendly to various pathogens. Another hypothesis says that Langerhans cells are a target of HIV, causing them to act as a vector. Since the relatively thin foreskin has these cells, that means there is an increased surface area and number of these cells where HIV can attach.

Other Benefits

Circumcision has been found to have a host of other health benefits (.pdf). UTI’s are decreased among newborns, penile cancers are reduced, general infections are reduced, and HPV is 30% less prevalent. One study from 1954 to 1997 that looked at cases of invasive penile cancer found that 87 out of 89 (98%) of the men were uncircumcised. Other studies have found a 30% decrease in contracting herpes.

Developed World Efficacy

The CDC has recently come out as endorsing circumcision has a healthy decision for parents to make. It’s a one time cost for a procedure with a low incidence rate of what are only minor complications anyway. The child feels no pain, there is no trauma, sensation isn’t affected at sexual maturation, and a host of diseases are reduced. If the CDC didn’t stop short of recommending circumcision as a health policy for political reasons, then they only did it because STD’s are not an epidemic in the United States. But, then, neither is the flu.

Condoms and Hygiene

The anti-circumcision crusader may get to this point and say, “Fine, even if everything to this point is true, it’s still undeniable that condoms, education, and basic hygiene can best take care of the major health issues raised here where Africa is concerned.” And that’s fair enough. Condoms are 97-99% effective at preventing sexual transmitted diseases. Retracting the foreskin and washing with soap and water will prevent most (maybe even all) infection. But this is a poor understanding of reality.

Let’s start with condom use. Even with wide spread education campaigns, millions of Americans have unprotected sex with untested partners every single day. STD’s are still transmitted here and teen pregnancy (and other unintended pregnancies) still exist. It strikes me as near-racist to assume that we can throw education and condoms at people in Africa and get great results. They aren’t monkeys we first worlders get to train. People in Africa will largely behave how people around the globe behave. Some will use condoms. Some won’t. Some will be willing but unable. Sometimes people run out of condoms and want to have sex. Sometimes they will have sex where they don’t happen to keep their condoms. Sometimes they want to take a risk because it feels better. The “they” here is global.

It’s obviously true that condoms and education are key components in the fight against HIV. However, we should never limit ourselves to one option simply because it may be the most effective option. This fight isn’t a zero sum game; we can – and should – use every tool available. Doing so will literally save lives.

As for hygiene, even with rigorous cleaning practices, infections can still happen. I have a friend who got circumcised in his early 20’s for this exact reason. He showered every day and was specific about his cleaning regimen, but he still had issues. That won’t be the case for everyone, but it will certainly be the case for many. It’s far easier to entirely prevent this issue after birth than to force men to see doctors later in life for something that needn’t be an issue.

Ethics

The anti-circumcision crowd has lost on the scientific front. Circumcision protects against HIV and other STD’s. It reduces penile cancers and other infections. It doesn’t hurt and it doesn’t alter sensitivity. Aside from the minor risks of surgery (which exist largely by virtue of what surgery is in the first place), it literally has zero physiological drawbacks. That leaves the anti-circumcision folks with limited recourse in the debate. Enter the ethical argument.

There is effectively only one ethical argument against circumcision. It isn’t a good one, but it does have a basis in established ethical theory. However, before I address that argument, I want to address a common philosophical argument I hear. It isn’t technically about ethics, but we’re in the same ballpark. It’s the argument that says removing the foreskin in order to protect against disease is like removing a foot to prevent foot cancer or gout. Eventually, the argument usually ends with the suggestion of death in order to prevent all disease. Even without the especially absurd end, this is nothing more than an argumentum ad absurdum. Removing a piece of skin which has no discernible function and the loss of which has no negative consequence is not the same as removing a significant body part or altering the body in a way which affects quality of life negatively.

The primary ethical argument against circumcision – the argument from bodily autonomy – is slightly better. This argument says that it is wrong to permanently alter a person’s body without their consent for non-medically necessary reasons. That means a haircut is fine, or even a piercing (though there may be other objections to the latter). Indeed, any life-saving procedure is allowed under this argument. Like with most ethical arguments, there will be examples that raise gray areas (and those will generally come down to personal judgement calls more than anything), but there are certain things that are black and white. Tattooing one’s infant wouldn’t be allowed, for example. The child necessarily cannot consent and the procedure is absolutely not medically necessary, so there is not justification for it.

With circumcision, it is true that the procedure is not medically necessary. All the benefits laid out above are still very much true, but that doesn’t make the procedure necessary. A person who doesn’t get circumcised can live a perfectly happy life, free from all sexually transmitted diseases and infections. Indeed, billions have done and are currently doing it. Furthermore, it cannot be reversed. Once that foreskin is gone, it’s gone. Some people will say it can be returned, but it will simply be extra skin, at best.

Now let’s make a comparison.

Vaccines are some of the greatest achievements of science. Everyone should get at least the basic vaccines we expect people in the 21st century to have. And for those who live in certain areas or travel to certain areas, a number of other vaccines are recommended. For instance, I have a vaccine for yellow fever because I visited Tanzania about 5 years ago. If I visit any similarly at-risk location 5 years from now, I’ll get a booster shot first. All that said: vaccines are not medically necessary. Again, they’re fantastic and everyone should get them. Public policy should dictate all students must get them. These are things which save lives. But, again, they are not medically necessary. Even when polio was a significant public health concern, very few people actually died from the disease. Only a small minority of the population ever contracted it, and of that small minority, only a minority became sick at all. It was great when a vaccine became widely available. Lives were saved. But being unvaccinated did not put someone at active risk of sickness or death; being unvaccinated was a passive risk. This exactly mirrors the issue with circumcision. Furthermore, vaccines cause permanent change to the body via the addition of anti-bodies. This again mirrors the permanent change of circumcision.

The first counter to this comparison is generally to note that anti-bodies aren’t a visible change whereas removal of the foreskin is. The argument from bodily autonomy makes no such exception. The argument doesn’t say it’s wrong to permanently alter a person’s body without their consent unless you totally can’t see it. That would entirely gut the argument, making it into nothing more than a cosmetic argument. Something so superficial doesn’t pass any sort of ethical muster in my book. Besides, I’m not so sure the anti-circumcision crowd should be making a cosmetic argument anyway.

The second counter to the circumcision-vaccine comparison is to note that whereas vaccines add something to the body, circumcision actually removes something. I suppose that’s true, but I don’t see where such a distinction would matter within the argument from bodily autonomy. We can no more rid ourselves of anti-bodies than we can rejuvenate foreskin.

Before I reach the end of this post, I want to quickly recap the argument from bodily autonomy. The argument says it’s wrong to permanently alter a child’s body without his consent unless it’s for a medically necessary procedure. Neither circumcision nor vaccines are medically necessary. Both are highly effective and both save lives. Without either, we would have fewer people in the world, that’s for sure. However, neither one is required to live a long, happy, and healthy life. This, of course, is not an argument against either one. This is an argument against this incantation of the argument from bodily autonomy. That isn’t to say bodily autonomy isn’t important. It is. But it isn’t an argument that works under the auspices of libertarian ethics as applied to global health issues. That is, bodily autonomy is important because it is the best way to protect the individual and populations at-large; it isn’t important in and of itself/because it maintains liberty. (Dead people don’t have liberty.) Or to put it another way, bodily autonomy only works under a utilitarian framework.

Conclusion

This one is simple. Circumcision is a safe procedure that needn’t cause pain, doesn’t cause trauma (indeed, it can’t cause psychological trauma by definition), and it doesn’t affect sexual sensitivity, satisfaction, or performance. Furthermore, it reduces female-to-male HIV transmission, invasive penile cancers, UTI’s, STD’s, and general infections. Along with education and condom use, circumcision is a phenomenal tool in the fight against HIV; circumcision literally saves lives. The World Health Organization, UNAIDS, the Bill and Melinda Gates Foundation, a dozen and a half African health ministries, the CDC, and the AAP all support it as good health practice. The science and the ethics are in: Excepting for the minor (and rare) risks inherent with surgery by virtue of what it is, there are literally zero drawbacks to circumcision; when performed under sterile conditions and by medical professionals, circumcision increases the odds a boy will have a disease and infection free life.