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Just a Bit Off the Top

June 21st, 2007 · 15 Comments

I realize Ross’ defense of circumcision in response to Andrew Sullivan’s most recent attack on the practice is somewhat tongue-in-cheek, but to the extent that it’s serious, it’s not all that cogent.

First, there’s the aesthetics. I’ve heard preferences in both directions here, but frankly, I’m not sure why this should cut in either direction (so to speak). An erect uncut penis isn’t going to look all that different from a circumcised one, and I’d expect that’s the state in which most aesthetic appreciation is going to take place, unless there are large numbers of people who sit around contemplating it flaccid like some objet d’art.

Hygiene invariably comes up in these conversations, but I’m a bit astonished this is thought to be such an important consideration in the modern world. I fully understand why the practice might have been adaptive, from a hygienic perspective, for nomadic desert people who didn’t have to worry about scratchy jungle underbrush but did have to worry about dust and infection given the relative paucity of showers. But I’m told we enjoy this wild innovation called “indoor plumbing” these days. I think they install it with your Internet broadband.

Finally, there’s the evidence that circumcision reduces genital sensitivity. Ross says:

Well, something like sixty percent of American males are so mutilated, and I believe I have the weight of the American experience on my side when I say that any such dampening would have to be extremely negligible.

Well, nobody’s saying circumcision turns sex into a tedious bore. But most of them don’t have a point of comparison, do they? My understanding is that people who’ve had the procedure as adults, however, do report noticing the difference.

Ross skips what seems like the most serious reason to perform what would otherwise be an unnecessary bit of surgery: The potential reduction of female-to-male HIV transmission. But that’s a benefit that comes into play once a person is sexually active, at which point one hopes he’s old enough to make an informed decision on his own, on the basis of an assessment of his individual risk profile.

Tags: Sexual Politics


       

 

15 responses so far ↓

  • 1 Kevin B. O'Reilly // Jun 21, 2007 at 7:11 pm

    Essentially, the only ethical justification for neonatal circumcision would be as a kind of preventive medicine.

    Do the benefits (slightly lower rates of penile cancer, eliminating the risk of phimosis, smaller risk of HIV contraction though that can be greatly minimized with condom use) outweigh the risks (a botched circumcision, somewhat less penile sensitivity)?

    Well, parents have to weigh that stuff with the advice of their physicians. But doing it for aesthetic reasons is wrong, and doing it routinely or without much discussion is wrong too. It’s not a no-brainer.

  • 2 Julian Sanchez // Jun 21, 2007 at 7:16 pm

    Well, I shouldn’t claim any real expertise here, but my sense here is that while (as you say) the HIV effect is both significant and achievable by other safe-sex practices, the other benefits are mild reductions in the probability of already-rare condition. My impression is that the latter are adduced after-the-fact to give a gloss of medical justification to a procedure that’s really being done for basically cultural reasons.

  • 3 FinFangFoom // Jun 21, 2007 at 8:08 pm

    I’ve heard from those who have experience in such things (i.e. women), that there is a noticeable difference in, uh, flavor. Even if its not a hygienic concern, in the strict sense, your junk starts getting funky pretty quickly.

  • 4 Joseph // Jun 21, 2007 at 8:13 pm

    Except umm I am pretty sure Ross was joking and not being serious-even semi.

  • 5 Glen Whitman // Jun 21, 2007 at 10:46 pm

    I basically agree with Julian, but I find this claim a bit odd: “once a person is sexually active… one hopes he’s old enough to make an informed decision on his own, on the basis of an assessment of his individual risk profile.” Thing is, a lot of people start having sex during their early teens — not an age bracket known for careful thinking about risk profiles and such. Should parents start having “do you wanna get circumcised” conversations with their sons at the age of 12?

  • 6 Ron Low // Jun 22, 2007 at 2:18 am

    1) There is no problem at all living with foreskin when there are no shower facilities. Think about it. Every mammal on earth evolved a foreskin before there was surgery or soap. Like the eyeball, the penis is self-cleaning.

    2) Do the benefits outweigh the risks for infant circumcision? No. This is the unanimous opinion of every medical association on earth.

  • 7 Neil the Ethical Werewolf // Jun 22, 2007 at 3:11 am

    Like the eyeball, the penis is self-cleaning.

    Being on the turtleneck-wearing side myself, I have to tell you that this isn’t exactly true. There’s plenty of area covered by the skin, particularly just after the glans, that needs a brief rinse when you’re in the shower.

    I don’t have any intentions of getting my turtleneck snipped into the more traditional sweater, but I’m not totally certain that the added sensitivity is a plus. Sometimes one wants to be a little less sensitive.

    I’m a little nervous about promoting circumcision as a solution to HIV in the third world, unless I can be totally confident that it’ll be done in a properly sterile way. That’s sometimes a problem out there.

  • 8 Kevin B. O'Reilly // Jun 22, 2007 at 8:09 pm

    Julian, you’re right that the other benefits are small. You’ll notice I didn’t suggest otherwise. But the risks are pretty small too. A straightforward discussion about the facts with parents will (and already has) reduced circumcision by a substantial margin. Simply presuming circumcision “is done” and not really discussing it with parents is wrong, and parents who make the decision based on aesthetics are behaving immorally. At that point, you’re just irreversibly body-modding your son because you feel like it. That’s not good enough.

    Until there’s much stronger evidence of harm from circumcision than what’s available now, the practice should certainly remain legal (i.e., mohels shouldn’t be forced underground).

    Ron is right that no major medical society recommends circumcision be done routinely for newborn boys, but none recommends against it either. They say just what I’ve said: discuss it with parents and let them decide.

  • 9 Tony // Jun 23, 2007 at 12:01 pm

    Essentially, the only ethical justification for neonatal circumcision would be as a kind of preventive medicine.

    and…

    Until there’s much stronger evidence of harm from circumcision than what’s available now, the practice should certainly remain legal…

    This is backwards. Your statements assume that the foreskin is guilty until proven innocent as a means of harm for the child. The only ethical position is to not impose unnecessary surgery on an individual who can’t consent. At the time it’s performed, routine infant circumcision is rarely medically indicated. As such, we can assume that a child wouldn’t consent. The evidence that intact adult men almost never choose – or need – circumcision demonstrates that.

    Like all claims of medical benefits, HIV “prevention” is nothing more than chasing a problem with a pre-determined solution. The reduction in HIV transmission risk is claimed to be 50%, but that lacks the context of how often it’s transmitted in female-to-male unsafe sex in which the female is HIV+. In absolute terms, that 50% reduction becomes a 1/200 risk rather than a 1/100 risk. (I think that’s roughly correct. I can’t find the latest claims, but the idea of context is correct, regardless.)

    From a libertarian viewpoint, it’s a violation. The boy gets no say in the matter, even though it’s clearly an elective body modification. Society tends to rely on some silly notion of parental “rights”, but if parents have that right for cultural reasons, the Female Genital Mutilation Act should be ruled unconstitutional for violating their right to modify their daughters. Appropriately, we’d all be shocked at such a ruling. But we’re supposed to accept tradition as sufficient reason for performing surgery on children. No. Obviously the right of one person to be free from harm is not trumped by the supposed right of another to impose his/her cultural body preference.

    Also, we can’t ignore that adult and infant circumcision are not the same, beyond the obvious point on voluntary versus involuntary. At birth, the foreskin adheres to the glans. (Just like female genitalia adheres. Neither is meant to be exposed until much later.) To circumcise an infant, the foreskin must be torn from the glans. The doctor (or mohel) can’t accurately judge what the child’s mature penis will be. His/her decision on how much or how little skin to remove is purely a guess. Too much and the boy ends up with painful erections. Too little and the boy likely ends up with readhesion, likely requiring further surgery. (This is common.) Ultimately, how much to remove is purely subjective. That should be left to the child.

  • 10 Kevin B. O'Reilly // Jun 23, 2007 at 12:22 pm

    Tony, how common is readhesion? How common are botched circumcisions?

    To me, those are key questions because as it is circumcision is almost always harmless and has some small medical benefits. I would not circumcise my children; I’d advise others against it. But to say that parents cannot legally choose to do something for their children about which the evidence is equivocal is to insert your preferences for theirs.

    I could argue that religious instruction is far more harmful to a boy than circumcision is, and therefore ban such instruction until the child reaches majority. But the evidence for that is lousy, just as the evidence that circumcision is harmful is pretty lousy. Just because circumcision is unnecessary — agreed! — doesn’t make it a human rights violation.

  • 11 Tony // Jun 23, 2007 at 3:31 pm

    Kevin,

    I don’t have the numbers handy. I’ll look them up and post them when I find them, although I suspect they’ll be less than firm. Such statistics aren’t standard, I think. However, (admittedly) anecdotal review of parenting blogs and forums will reveal that it’s more common than people believe.

    To your analysis, I’m not saying that parents can’t do something for their children where the evidence is equivocal, although the fact that it is equivocal indicates that the law should err toward caution in favor of the child. But this specific something is genital surgery without medical indication. No amount of equivocal benefit can overcome that. Medically unnecessary circumcision demands a standard far different than whether it’s wise for parents to feed their kids at McDonald’s every fourth day. There is a very clear reason to prohibit unnecessary surgery, especially when every benefit can almost always be achieved with far lesser preventions and/or treatment.

    I’m curious. Why is it wrong for me to insert my preference in place of parents on a medically unnecessary surgery, but it’s okay for parents to insert their preference in place of their child’s? Proxy consent? I don’t think so. We’re not talking about medicine versus removal to cure tonsillitis. Again, this is medically unnecessary surgery, consisting of a specific, unavoidable risk of complications, including death. Are the few children who die from the procedure an unfortunate byproduct of respecting parental choice? The greater number of children who suffer severe complications short of death?

    Religious instruction as an argument is informative. My parents made me go to church for a few years in my teens. I despised it because I’m not religious and I didn’t buy into what I was being told. But I’ve overcome that because I grew up and came to make decisions for myself. The potential for destructiveness was there, but it was not guaranteed. I retained the choice, however different my success may have varied from that of other children.

    With circumcision, the loss of the foreskin is guaranteed. The foreskin serves a purpose, both in protecting the glans and providing sexual gratification. The loss of those may have a subjective value, but only the circumcised can deem it accurately. Parents are not psychics.

    For me, I can’t now reject my parents’ decision, even though I never would’ve chosen it. There is no alternative. I’m not about to respect this as a valid parental option.

    Without veering the conversation too far off course, we don’t allow any such decision for parents of females. Not even a symbolic pinprick to adhere to cultural conditioning is acceptable. That’s far less invasive than what’s done to boys, but still we can find the obvious truth that girls have specific rights that their parents can’t violate. I’m not willing to subscribe to a belief that gender matters in protecting rights through the prohibition of unnecessary genital cutting.

  • 12 Tony // Jun 23, 2007 at 9:10 pm

    Kevin,

    As I expected, statistics aren’t easy to find, while anecdotal reports abound. Here’s what I’ve found so far.

    First, some numbers:

    This study from 1984 found a 15% readhesion rate among circumcised boys, with 3% of circumcised boys (20% of the boys with readhesion) needed surgical correction.

    This study from 1997 found a 25.6% rate of readhesion. No mention is made of how many needed surgical intervention to correct this.

    This study from 2000 studied a wide range of ages. It found rates across the age groups (listed in the link) of 71%, 28%, 8% and 2%, decreasing as the boys got older.

    To be fair, the last study found that surgical intervention was rarely called for. But it did bring up another complication, skin bridges. Rather than readhere, the tip of a foreskin remnant adheres, leaving a gap between the remnant and the penis.

    Obviously there’s a disparity in these numbers. Sample size may play a part, as well. I haven’t read the studies closely, so I can’t vouch for them. I’m sure the significant number here is also the 3% needing additional surgery. Again, that number may be off, but I suspect it’s close enough to get an idea that some additional intervention, whether requiring anesthetic or not, may be necessary from the “harmless” original surgery.

    What seems clear is that circumcision is not the “cut it and forget it” miracle it’s portrayed to be. Many parents think that an intact penis is too complicated and they don’t know what to do. But it actually involves nothing more than basic cleaning without retraction. The parents who circumcise end up with at least a week’s worth of effort while the wound heals. Then some percentage are stuck with more work to prevent and/or correct adhesions and other complications. One anecdotal report I read involved effort for the first several years of the boy’s life.

    What about the boy who has to endure his parents pulling his foreskin back to prevent this, when they wouldn’t have to do anything (and shouldn’t do anything) if they left him intact?

    Now a couple of anecdotal links:

    Here’s a father’s story about his son’s unexpected surprise and here’s a Q&A message board with a lot of “my son, too” comments. Not all need surgery, but the point is that unexpected results occur.

    Let me know if you want me to do any more digging.

  • 13 Kevin B. O'Reilly // Jun 23, 2007 at 9:12 pm

    I was thinking about the FGM issue today. The analogous situation would be if there were a cultural/religious practice about removing the clitoral hood. Then we could talk about it. But as FGM is actually practice there’s really no comparison is there?

    Why is it wrong for you to insert your preference for parents? For the same reason that it would be wrong for you to insert your preferences regarding any nonabusive/neglectful parental activity. Do you think circumcision is a form of child abuse? How far do we go here?

    Anyway, what are boys being protected from by banning circumcision? What is the evidence of harm? And how does it compare to the evidence of harm from inaction? To me, that’s the key question to be examined by physicians and parents and that ought to be studied in a more rigorous scientific fashion.

    I’m all for leaning against cutting. I think it’s unnecessary, and I think the effort to get parents to think twice and three times about doing it is laudable. I’m glad to read of the trend of some Jewish parents having faux brisses where circumcision doesn’t take place. And the thing that bothers me most is when parents justify circumcision on aesthetic grounds — it makes me sick to my stomach.

    Other issues:
    (1) Anesthesia is used today, and I’m fine with requiring that it be used wherever it isn’t.
    (2) I’m glad with requiring mohels to have greater training to reduce risks there. I don’t see any problem with requiring that religious rite to take place within a medical context or be performed by a mohel with a medical background.

  • 14 Tony // Jun 24, 2007 at 10:22 am

    The World Health Organization recognizes four types of female genital mutilation. Most of them are indeed far worse, quantitatively, than what is done to boys, and the forms most commonly practiced are the most destructive.

    However… Type I without excision of the clitoris involves only removing the clitoral hood. Type IV can involve “merely” pricking or piercing the clitoris. There is an easy, accurate analogous comparison that can be made, and these forms are practiced. Yet federal law (correctly) prohibits all forms of FGM for any non-medically necessary reason. The Constitution guarantess equal protection, so there are only two options. If parents can’t chase benefits or make their daughters in their own image, boys must be equally protected. Or we can allow female genital cutting. I’m not about to support the latter. No one is. So why are we left with irrational defenses of potential benefits and cultural conditioning for boys to justify what is, qualitiatively, the exact same thing: medically unnecessary genital cutting on a non-consenting individual? Even if we disregard non-consenting because of proxy consent, we’re left with medically unnecessary.

    (For consideration, read this story. Skip to the part about Seattle. Less damaging. Should we have allowed it? There’s a debate to be had, but the reflex reaction that there is no comparison is simply untrue. There are also several prominent women who suffered FGM who speak out against both, equating the ethical, human rights violation of the two procedures.)

    Specifically, you say that male circumcision is nonabusive. I disagree. Child abuse is not the term I’d use for circumcision. I’d use assault. Well-intentioned assault, but I don’t think good intentions is enough. I’m far more concerned with the act than the justification.

    I’m still confused how you can question the evidence of harm. 100% of boys suffer scarring. That’s harm. And as you say, infant circumcision for aesthetic purposes is maddening. Why should we believe that children want their body scarred on purpose? And for something that is undeniably subjective, why should we allow it? Again, intact adult males almost never choose (or need) circumcision. This is enough to dictate prohibiting parents from using this justification. If we don’t, we end up prohibiting circumcision except where it’s medically necessary or part of the parents’ religion. How many parents will suddenly find a religious justification? Christians included, since I’ve talked to many of them who use the Old Testament, even though the New Testament supercedes and discards the commandment.

    A percentage of boys encounter other minor complications. Some have severe complications. I don’t think you deny those, but I wonder why the possibility that those will occur isn’t enough. Parents are not psychics. They can’t know which outcome their child will have. The risk he faces is not medically necessary. If scarring is the only negative outcome, as deemed by someone other than the boy, he still faces that risk. That is unjustifiable.

    As to the harm of inaction, that’s not helpful. If we’re going to use that as a criteria for surgery on children, far more females get breast cancer. We correctly don’t intervene there. Heck, more males get breast cancer than get penile cancer, yet we think “preventing” penile cancer is a spiffy reason to cut. It’s absurd. For every single risk associated with inaction, there is a simpler, more effective prevention and/or treatment in almost every case. I won’t concede that we should allow proxy consent to perform medically unnecessary surgery based on the extremes.

    Through prohibition, some number of boys will be prevented from severe penile damage. Some number of boys will be protected from loss of the penis. Some number of boys will be protected from death. The rate of these most severe complications is small, but in our society of individual rights, how many boys must suffer severe damage before we default to protecting their healthy bodies from intervention until something goes wrong? What is the utiliatarian price on boys to protect parental choice?

    Let me ask you another question: what about men like me who would never have chosen circumcision for ourselves? Circumcision wasn’t medically necessary and can’t verifiably be said to have prevented anything for me. I don’t get any HIV benefit now that we “know” it works. I know condoms and monogamy work better, which is why I practice them. I would still only practice those if I had the choice. Is our right to not have our bodies altered without our consent worthless until we’re 18 so that our parents can apply their subjective opinions to our bodies?

    P.S. One clarification with issue (1) you listed. Anesthesia is not used on infants because it’s unsafe. At best they are given topical analgesic and dorsal penile block. These are not 100% effective at preventing pain. The dorsal block involves an injection into the penis, which I imagine hurts. Once the surgery is complete, the wound will hurt throughout the healing period, particularly during and after urination. Some pain medicine will be administered, but it’s undeniable that the child will be in pain throughout that period. Surely that matters in the discussion.

    Even if we can achieve 100% pain relief (how would we test this on an infant who can’t communicate fully?), the ability to make an operation pain-free is not a justification for that. At best, it’s a humane consideration. When applied to an inhumane procedure, that’s little consolation. I don’t think you believe that pain relief excuses circumcision, but I’ve read parents and doctors who do. They seem willing to ignore the obvious logical continuation that we can make any number of procedures pain-free. That doesn’t magically make those procedures ethical.

  • 15 Tony // Jun 25, 2007 at 11:27 am

    (I posted this yesterday. Since it never showed up, I’m guessing the spam filter ate it. Or maybe it’s too long?)

    The World Health Organization recognizes four types of female genital mutilation. Most of them are indeed far worse, quantitatively, than what is done to boys, and the forms most commonly practiced are the most destructive.

    However… Type I without excision of the clitoris involves only removing the clitoral hood. Type IV can involve “merely” pricking or piercing the clitoris. There is an easy, accurate analogous comparison that can be made, and these forms are practiced. Yet federal law (correctly) prohibits all forms of FGM for any non-medically necessary reason. The Constitution guarantees equal protection, so there are only two options. If parents can’t chase benefits or make their daughters in their own image, boys must be equally protected. Or we can allow female genital cutting. I’m not about to support the latter. No one is. So why are we left with irrational defenses of potential benefits and cultural conditioning for boys to justify what is, qualitatively, the exact same thing: medically unnecessary genital cutting on a non-consenting individual? Even if we disregard non-consenting because of proxy consent, we’re left with medically unnecessary.

    (For consideration, read this story. Skip to the part about Seattle. Less damaging. Should we have allowed it? There’s a debate to be had, but the reflex reaction that there is no comparison is simply untrue. There are also several prominent women who suffered FGM who speak out against both, equating the ethical, human rights violation of the two procedures.)

    Specifically, you say that male circumcision is nonabusive. I disagree. Child abuse is not the term I’d use for circumcision. I’d use assault. Well-intentioned assault, but I don’t think good intentions is enough. I’m far more concerned with the act than the justification.

    I’m still confused how you can question the evidence of harm. 100% of boys suffer scarring. That’s harm. And as you say, infant circumcision for aesthetic purposes is maddening. Why should we believe that children want their body scarred on purpose? And for something that is undeniably subjective, why should we allow it? Again, intact adult males almost never choose (or need) circumcision. This is enough to dictate prohibiting parents from using this justification. If we don’t, we end up prohibiting circumcision except where it’s medically necessary or part of the parents’ religion. How many parents will suddenly find a religious justification? Christians included, since I’ve talked to many of them who use the Old Testament, even though the New Testament supersedes and discards the commandment.

    A percentage of boys encounter other minor complications. Some have severe complications. I don’t think you deny those, but I wonder why the possibility that those will occur isn’t enough. Parents are not psychics. They can’t know which outcome their child will have. The risk he faces is not medically necessary. If scarring is the only negative outcome, as deemed by someone other than the boy, he still faces that risk. That is unjustifiable.

    As to the harm of inaction, that’s not helpful. If we’re going to use that as a criteria for surgery on children, far more females get breast cancer. We correctly don’t intervene there. Heck, more males get breast cancer than get penile cancer, yet we think “preventing” penile cancer is a spiffy reason to cut. It’s absurd. For every single risk associated with inaction, there is a simpler, more effective prevention and/or treatment in almost every case. I won’t concede that we should allow proxy consent to perform medically unnecessary surgery based on the extremes.

    Through prohibition, some number of boys will be prevented from severe penile damage. Some number of boys will be protected from loss of the penis. Some number of boys will be protected from death. The rate of these most severe complications is small, but in our society of individual rights, how many boys must suffer severe damage before we default to protecting their healthy bodies from intervention until something goes wrong? What is the utilitarian price on boys to
    protect parental choice?

    Let me ask you another question: what about men like me who would never have chosen circumcision for ourselves? Circumcision wasn’t medically necessary and can’t verifiably be said to have prevented anything for me. I don’t get any HIV benefit now that we “know” it works. I know condoms and monogamy work better, which is why I practice them. I would still only practice those if I had the choice. Is our right to not have our bodies altered without our consent worthless until we’re 18 so that our parents can apply their subjective opinions to our bodies?

    P.S. One clarification with issue (1) you listed. Anesthesia is not used on infants because it’s unsafe. At best they are given topical analgesic and dorsal penile block. These are not 100% effective at preventing pain. The dorsal block involves an injection into the penis, which I imagine hurts. Once the surgery is complete, the wound will hurt throughout the healing period, particularly during and after urination. Some pain medicine will be administered, but it’s undeniable that the child will be in pain throughout that period. Surely that matters in the discussion.

    Even if we can achieve 100% pain relief (how would we test this on an infant who can’t communicate fully?), the ability to make an operation pain-free is not a justification for that. At best, it’s a humane consideration. When applied to an inhumane procedure, that’s little consolation. I don’t think you believe that pain relief excuses circumcision, but I’ve read parents and doctors who do. They seem willing to ignore the obvious logical continuation that we can make any number of procedures pain-free. That doesn’t magically make those procedures ethical.

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