“Since not all men are willing to be circumcised, …” (Part 1)

Update (5/31/2012): I modified the first paragraph to focus my jabs. I should not have been as broadly rude as I was. I have great contempt for Brian Morris, but he should’ve been the only target for that contempt. The other authors merely frustrate me via either personal interactions or their public statements. In my interactions with Mr. Waskett, specifically, I haven’t experienced the contemptible behavior so easily witnessed from Morris. I regret that mistake.

A long list of familiar names have conducted a meta-analysis of a bunch of studies involving circumcision. The article purports to ask the question “What is the best age to circumcise?”. (Notice the implicit assumption that a male should be circumcised.) They don’t address that question, of course, instead answering “How can we encourage infant circumcision?”. They only justify it in their minds because their analysis is lacking. I didn’t expect anything better after seeing Brian Morris attached to it. (Jake Waskett, Aaron Tobian, Ronald Gray, Robert Bailey, Daniel Halperin, and Thomas Wiswell, among others, are listed as co-authors.)

I’ll probably post more extensive critiques because it all deserves as public an airing as possible. Their credibility deserves to be attached to this awful piece of scholarship. For now, I want to focus on this, from the section titled “Is infancy the best time medically?”. It offers a succinct example of their incomplete, flawed approach.

All boys are born with phimosis. This resolves by about age 3 in all but approximately 10% of males, who as a result experience problems with micturition, ballooning of the foreskin, and painful difficulties with erections (see review [9]). Paraphimosis can similarly be prevented by infant MC.

This is silly. All boys are born with phimosis? That’s a stupid way to explain normal human development. They’re pathologizing the healthy infant foreskin to justify the conclusion they want to reach. How many of those boys in the 10% will have their foreskin naturally separate (i.e. “resolve”) after age 3 and will never need any intervention to achieve this? They’re implying that an intervention is necessary for healthy, intact three-year-old boys whose foreskin hasn’t fully separated. (The whole paper is that, except stated rather than implied.)

Throughout the paper, they never consider the important question when reaching the conclusion that something can be “prevented by infant MC”: how many legitimate instances of phimosis/paraphimosis/UTI/whatever require circumcision later in life because another, less invasive intervention is insufficient. They declare that the risk in intact males “of developing a condition requiring medical attention over their lifetime = 1 in 2”. (I’ll grant that because it doesn’t alter the conclusion on non-therapeutic infant circumcision.) They never identify how many of those require circumcision. Yet they use this 50% figure as a justification for infant circumcision. The need for circumcision rather than the need for medical intervention is what’s relevant. Their focus is mistaken and leads to their incorrect conclusion.

In the “Cosmetic Outcome” section, they write:

When circumcision is performed in infancy the ability of the inner and outer foreskin layers to adhere to each other means sutures are rarely needed and the scar that results is virtually invisible [98]. Other factors include the more rapid healing at this time of life, contributed by age-associated differences in pro-inflammatory factors that might affect scar formation [145].

Once again they’re using normal human development to manipulate a path to their predetermined conclusion. They’re using a convenient aspect of the surgical procedure rather than medical need to justify imposing the surgical procedure.

The ability of an infant’s inner and outer foreskin layers to adhere to each other once cut also demonstrates that boys are not born with phimosis. This ability is evidence that the normal foreskin is not supposed to be separated from the rest of the penis at birth. Neither argument is a valid defense of infant circumcision, but the authors can’t have both in their attempt. Doing so is just a way of presenting the preferences they like as the only preferences worth considering. That’s biased by the authors’ utilitarianism. Remember when I wrote “[t]he utilitarian approach is subjective and has a tendency to favor whatever argument someone is making because it assumes all people favor the same choices”? Their article is a perfect example of that.

Since that ability is classified under “cosmetic outcome”, let’s discuss that. My circumcision healed the way they suggest. The scar did not heal “virtually invisible” for me. Any cursory review of pictures of circumcised penises will show that the scar is almost always quite visible. My complexion is very light, so I suspect my scar is less visible than what most males experience. But it’s still quite visible. They’re wrong. This error is inexcusable.

Perhaps the cosmetic outcomes of circumcision, infant or adult, are desirable to Morris, Waskett, et al. They’re entitled to their opinions about their own bodies. It does not follow that parents who share that preference may force those onto the body of a child – male only – who may not share that preference. The cosmetic outcome of circumcision is hideously ugly to me. I wouldn’t choose it for myself if I still had my choice. I am not the only one, since not all men are willing to be circumcised. The author’s opinion or statistics on female preferences about a male’s normal body are irrelevant until and unless the individual decides he wants himself circumcised.

Unsurprisingly, the authors never discuss male preference in the Ethics section. (More on that later.) The title of this post is the closest they get to mentioning the possibility. They mistakenly use that sentiment to reach the conclusion that infants should be circumcised. They endorse the view that if you can’t convince someone, promoting its imposition on them is somehow defensible. It isn’t.

5 thoughts on ““Since not all men are willing to be circumcised, …” (Part 1)”

  1. This long analysis of rubbish wasn’t even necessary. The very premise is already flawed, from the beginning. The question shouldn’t be “when,” but “why,” which the authors assume to be a bygone conclusion.

    The paper assumes there is a consensus in medicine that says the foreskin causes nothing but problems and must be removed as soon as possible. The fact of the matter is that this is purely the opinion of these so-called “researchers,” and they are trying to give themselves an air of credibility by clothing it in science. The fact of the matter is that the opinion of circumcision in western medicine is overwhelmingly negative; no medical organization in the world recommends the circumcision of infants, not even in the name of HIV prevention. They must all point to the risk, and they must all say that there isn’t enough evidence that says the so-called “benefits” outweighs these risks. To do so would be to take an unfounded position against the best medical authorities in the west, as Morris et al are doing here.

    What non-circumcising country has half their men lining up to be circumcised because their foreskins are causing them problems? What is the reason HIV is more rampant in the US, where 80% of all males were circumcised from birth, than in various countries in Europe where circumcision is rare? What is the reason some of the highest rates of HIV transmission in Africa happen to be in communities where 100% of the men are circumcised? These men are cherry picking statistics to get the “compelling” numbers they want. And when we see the men behind this “study” we can see why.

    The way standard medicine usually works is, there needs to be a medical necessity for surgery, one that cannot be remedied in any other way, and all other methods of treatment have failed.

    Here, we observe, that self-serving “researchers” with agendas are trying to flip medicine on its end, seeking ways to necessitate surgery as opposed to trying to do away with it. The fact that they’re trying to make a superfluous procedure necessary should raise the first red flags.

    I should note, it’s interesting how in this paper they attempt to pathologize a normal stage of development. It just shows you how out of touch these “researchers,” really are. Newer data shows that the foreskin commonly becomes retractable at later ages than previously thought. Perhaps they are purposefully ignorant of newer data because it does not fit within their agenda to make child circumcision an indispensable necessity?

    Do not analyze further than the title and the names if the usual suspects all lined up in a row. This is pure junk science that shows that something is wrong with the peer review process. There is something wrong when all you need to do to get garbage published is find peers that agree with your opinion. This study is complete rubbish and sooner or later it is going to end up in history’s dust bin where it belongs.

  2. I’ve just remembered; phimosis can only be diagnosed in males whose foreskin cannot retract due to a stricture in the foreskin caused by an infection with balanitis xerotica obliterans (BXO).

    To say that all children are born with phimosis is categorically false.

  3. Most boys in the US are circumcised and as they move into jnoiur high and high school, they shower together. Some boys feel strongly about wanting to fit in and therefore like being circumcised. This may have been true for our generation, when circumcision was routine, but I’m sure if you fact checked you would find that it’s close to 50/50 now. So no, most’ boys are not circumcised now a days. As for the fitting in, if another boy is making fun of my son for being intact, I’m sure my boy (& the others) will wonder why he is looking at their penis’. Who won’t fit in then? Honestly, i don’t understand what the debate about circumcision is, we don’t cut off any other healthy body parts, even ones that may one day cause medical issues, why do we cut off foreskin?Where does it end? Some studies show that circumcision reduces the risk of urinary tract infections, perhaps meningitis and it lowers the risk of penile cancer. Studies show that having an appendectomy will lower the risk of appendicitis, let’s start doing that at birth too!And tonsils, what about that? They get infected, probably better to cut those out. I bet it will be easier at birth, going by your logic!Cutting of viable, healthy body parts to prevent medical issues that may’ arise sounds silly when you look at it that way. Why would foreskin be different?Did you know that 100% of botched circumcisions are preventable by not circumcising!!? I often leave the decision about circumcision of sons to the father. Many fathers have strong opinions and I feel that it is important to honor those decisions. Funny, i feel that we should leave important choices about someone’s body up to the person that owns the body, not someone else. Their body, THEIR choice.Little boys are born PERFECT, leave them that way!

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