Subjective versus Objective in Infant Circumcision

Slate Star Codex’s 2019 Adversarial Collaboration Contest includes an entry called, [ACC] WHAT ARE THE BENEFITS, HARMS, AND ETHICS OF INFANT CIRCUMCISION?. It’s a confusing mess.

It starts with two paragraphs on penile cancer that reveal this collaboration needed more rigor in the analysis. The beginning:

Circumcision greatly reduces the relative rate of penile cancer, a relatively uncommon malignancy in developed nations which kills a little over 400 American men each year. Denmark, while it has one of the lowest rates of penile cancer for a non-circumcising country, nevertheless has 10x the rate of penile cancer as Israel – where almost all men are circumcised. …

First, the relative rate reduction is marketing. The absolute reduction is the important bit. If I play the Powerball, how much better off am I between buying one and two tickets? The odds are 1 in 292,201,338 with one ticket and 2 in 292,201,338 if I buy two. My relative chance of winning doubled but my absolute chance of winning barely budged. I wouldn’t quit my job when I handed over money for the second ticket.

But there isn’t a source for the relative risk reduction, only an assurance that it’s greatly reduced. The link only states that penile cancer is “diagnosed in less than 1 man in 100,000 each year and accounts for less than 1% of cancers in men”. There are four-and-a-half times as many testicular cancer cases and an equal number of deaths each year, for perspective. Would it make sense to consider removing a testicle from each newborn male? Still leaves him fertile, so what’s the objection, right?

In the second sentence, the science analysis switches to a comparison between Denmark and Israel. Mentioning A before ignoring A to compare B and C is odd. It would be better to consider controlling variables, since there’s clear evidence of complexity within the rates in the three countries.

Here’s a statistic for penile cancer in Denmark from pro-circumcision advocate Brian Morris (use Google, I’m not linking him). He states:

Since the rate of penile cancer in Denmark is lower than in the USA other factors besides circumcision are also at work in these climatically, genetically, dietarily and culturally different countries. The statistics for Denmark have been used by anti-circumcision advocates to draw a sweeping and fallacious conclusion about lack of circumcision per se in penile cancer. The Danish themselves have concluded that although their uncircumcised men are at lower risk, this is only 1 in 900 as opposed to 1 in 600 in the USA, as stated above [Kochen & McCurdy, 1980]. …

So, a country with little circumcision has a penile cancer rate lower than the United States, which has a mostly circumcised male population, and the conclusion we’re to draw is that circumcision greatly reduces the risk of penile cancer. Morris’ twisted barb is the mistake he’s making. I’m not claiming there’s no effect on penile cancer with still having one’s foreskin. The risk factors are generally known and accepted: HPV, phimosis, smoking, age, and being intact. Which is to say, get vaccinated for HPV and/or wear condoms, resolve phimosis if it occurs, don’t smoke, and wash your penis regularly.

I’ll leave out “don’t get old” because I don’t think the most radical solution is the best first option, which is the same reason I leave out “circumcise healthy children”. But if an adult wants to get himself circumcised because he’s afraid the above actions aren’t sufficient, I’m not here to judge his decision. I assume his risk will decrease by some amount. That’s his choice, if he concludes the risks and harms from circumcision are less to him than some reduction in the risk of penile cancer, among potential benefits.

In the essay, the authors write about phimosis:

… However, this does raise the question of whether more aggressive future treatment of phimosis combined with HPV vaccination might reduce the rate of penile cancer in uncircumcised men in the future somewhat. Of course, more aggressive treatment of phimosis would require more childhood circumcisions, which carry higher risk than infant circumcision.

More aggressive treatment of phimosis does not require more childhood circumcisions. It requires understanding the difference between normal anatomical development and phimosis, and not letting a condition linger untreated when it appears. The key is to avoid long-term scarring, not to operate at the first hint of a malady.

According to the United Kingdom’s National Health Service on phimosis:

Surgery may be needed if a child or adult has severe or persistent balanitis or balanoposthitis that causes their foreskin to be painfully tight.

Circumcision (surgically removing part or all of the foreskin) may be considered if other treatments have failed, but it carries risks such as bleeding and infection.

This means it’s usually only recommended as a last resort, although it can sometimes be the best and only treatment option.

Alternatively, surgery to release the adhesions (areas where the foreskin is stuck to the glans) may be possible. This will preserve the foreskin but may not always prevent the problem recurring.

We must abandon the notion that the most radical intervention should be used as early as possible.

(Also, a higher risk rate later is not in the criteria for operating on a normal, healthy child now.)

The next section on HIV mostly summarizes the consensus, while once again missing the importance of relative versus absolute risk, as well as comparing populations where the studies took place and the extrapolation of that data to other populations. The AAP did that in the technical report of its (now-expired) 2012 policy statement on infant circumcision.

… Mathematical modeling by the CDC shows that, taking an average efficacy of 60% from the African trials, and assuming the protective effect of circumcision applies only to heterosexually acquired HIV, there would be a 15.7% reduction in lifetime HIV risk for all males. …

That is a 15.7% relative reduction in lifetime HIV risk in the United States. The lifetime absolute risk of HIV is estimated at 1 in 99. That minor reduction of a small risk is the compelling benefit within the context of STIs, according to the article.

How compelling is it as a defense of infant circumcision when you factor in that the studies were conducted on adult volunteers, not children who are more than a decade from sexual activity and can make their own voluntary choice as an adult?

There is an interesting quote within the section:

… Additionally, when considering the benefits and harms of an intervention such as circumcision, there are strong reasons not to consider the benefits that accrue to the patient’s future partners, but instead to focus only on the individual in question.

The article doesn’t directly treat it this way, but that is the beginning of the discussion because the analysis approaches ethics. The same applies to consideration of the cultural benefits that accrue to others (i.e. primarily parents, but also “locker room”, etc). It’s the start of “should we” rather than the “can we”.

For UTIs, the risk reduction is in the first year of life, the risk is already low, less invasive treatments are available (which we use for girls), and while that benefit lasts for the first year, the harm from the surgery lasts a lifetime. Once again, it’s an ethics question, not a “can we” question.

For the risks of surgery, I think there are clear problems in the numbers. The incidence rate of meatal stenosis is telling, for example. This study reviewed meatal stenosis as a late complication, with follow-up assessment of the two groups at 2 months, 12 months, and 16 months. The group with the lower rate of meatal stenosis at 16 months had a rate of 13.8%. The implication seems clear. Infants can’t report complications. Maybe parents are ignorant of complications. Or maybe they’re not reported in a central location to be included in analysis.

And what constitues a complication? Is a poor cosmetic result a complication? What if the parents think their son’s circumcised penis is pretty but he hates the aesthetic? Is that a complication? Is it factored into the “< 0.2%"? Would it be a complication if a 25-year-old man chose circumcision for himself and didn't like it?

Moving on to sensitivity and sexual satisfaction, I’ll note a few things. The study the authors link to for a claim that the glans “does not change in sensitivity” has Brian Morris as a co-author. I find that immediately discreditable, but I acknowledge that’s isn’t relevant to whether any specific work is flawed. It is not evidence.

What’s in their review is evidence, though. Morris and his co-authors generally play “heads I win, tails you lose” when analyzing information about circumcision. For example, in assessing the Meissner’s corpuscles in the foreskin, they write:

… the study concluded that the prepuce is the least sensitive glabrous tissue of the body.

These findings suggest that the prepuce has fewer Meissner’s corpuscles than any other glabrous skin and that the number of these nerve endings decreases significantly after the teenage to young adult years when sexual activity begins. This makes it very difficult to propose any sexual function for Meissner’s corpuscles. A more feasible hypothesis is to regard them as a juvenile phenomenon, perhaps serving to protect the penis until the onset of puberty reveals its sexual function.

The areas in the study were “finger tip, palm, sole, lip, front for forearm, dorsum of hand, dorsum of foot, and preputium of penis”. All had Meissner’s corpuscles. Based on the numbers, concluding that the foreskin is the least sensitive glabrous tissue contains the fact that it is sensitive. There’s no value to this sexually? No one has ever used light touch of fingers, palms, soles, lips, forearms hand, or feet to generate sexual arousal and provide sensation? Is the proper conclusion that some number above the sensitive-but-least area is the threshold above which sensitivity matters for sexuality? This is choosing not to know.

Now ponder a more recent study with a very specific finding about the foreskin. From Brian Earp’s review:

So let me try another analogy. Saying that removing the foreskin “doesn’t reduce penis sensitivity” is a bit like saying that removing the pinky finger doesn’t reduce hand sensitivity. What you really mean is that removing the pinky finger (which is part of the hand) doesn’t reduce sensitivity in the remaining fingers—although, as we’ll see, it’s not even clear that this part of the analogy holds up in the actual study.

…

Again, you will be surprised to learn—I am quoting directly from the paper now—that “Tactile thresholds at the foreskin (intact men) were significantly lower (more sensitive) than all [other] genital testing sites” including the sites in circumcised men (emphasis added).[5]

And if you’re still unsure based on everything above, here’s a quote from Brian Morris, in his own press release:

… Delay puts the child’s health at risk and will usually mean it will never happen.

The child’s health is “at risk”, but if circumcision isn’t imposed early, he’ll usually neither need or choose circumcision in his lifetime.

Finally, the discussion of ethics:

The ethics of infant circumcision is a complex topic, and the answers likely depend on one’s ethical system. The benefits of infant circumcision appear to outweigh the risks and harms. Additionally, it is safer to be circumcised as an infant than as an adult, and a significant portion of the benefits of circumcision accrue to infants and children. From a strictly utilitarian perspective, infant circumcision should therefore be encouraged – whether we consider society as a whole or only the boy in question. However, autonomy is an important value, and while a man can become circumcised (missing only some of the benefits of having been circumcised as an infant), it is impossible to effectively restore the foreskin and become “de-circumcised”. An ethical system that heavily values personal choice over cost-benefit analysis may reasonably reject circumcision – especially one that rejects currently-widespread societal assumptions about parents making medical decisions for their children. Furthermore, many of the benefits of circumcision accrue only to men who have sex with women. For men who exclusively have sex with men and for men who do not have sex, the benefits and risks are close to equipose. There is a moral concern with performing a procedure that can thus tend to reinforce heteronormativity and sex-normativity.

The answers on circumcision depend on including the healthy individual in the ethical system for a decision that affects him alone. The benefits of infant circumcision only outweigh the risks and (potential and guaranteed) harms if the individual’s subjective preferences value the benefits more than the risks and (potential and guaranteed) harms. To the extent that there is certainty that infant circumcision is safer, delaying circumcision “will usually mean it will never happen”, and no unnecessary surgery is safer than unnecessary surgery. From a strictly utilitarian perspective, infant circumcision demonstrates the flaw in applying a strictly utilitarian perspective on human rights. That anatomy is an important value is the critical point to dismiss allowing imposing subjective preferences on another forever. The man the boy becomes may not share the preferences of his parents. He can’t be uncircumcised if they impose their will. An ethical system that heavily values the current widespread societal assumptions about the valid limits on the imposition of surgery on a daughter’s normal genitals for the parents’ non-therapeutic preference(s) is reasonable to apply to boys, as well. Furthermore, many of the benefits of circumcision accruing only to men who have sex with women are still of subjective value and can be chosen as an adult. For men who exclusively have sex with men and for men who do not have sex, the benefits, risks, and harms are still subjective to the individual himself. There is a moral concern with performing a procedure that is unnecessary and permanent on an individual who does not actively consent.

Non-therapeutic infant (and child) circumcision is unethical.