Flawed Circumcision Defense: Jesse Bering

“It requires education to see the world through disease-coloured glasses.” – Thomas Szasz (“Circumcision and the birth of the therapeutic state”)

Jesse Bering, PhD, endorses the AAP’s revised policy statement on non-therapeutic male child circumcision. He asks readers to replace the God he doesn’t believe in with the god he does believe in. He starts with some introduction about himself being circumcised, while his partner is intact. He then writes:

Whatever the reasons that previous generations may have had for choosing to remove their infant sons’ foreskins, they were almost always unconvincing. All else being equal – … – all else being equal, any dubious benefits derived from religious, social, hygienic, or aesthetic reasons are clearly outweighed by the costs of male circumcision. …

It might be surprising that I disagree with that. The costs clearly outweigh the benefits for me, then and now. But I do not believe that’s an objective conclusion for everyone. Each person has his own preferences unique to himself. It’s not for me to demand that anyone accept my opinion for myself as a substitute for his own opinion about his body. This involves the individual and his lack of need, and what those two details require for proxy consent.

Today, however, all is no longer equal, and the balance between the relative risks and benefits of male circumcision has clearly shifted in the other direction. That is, it has according to the American Academy of Pediatrics, which just earlier this week put out its revised position statement on infant male circumcision. Here’s the money quote:

Systematic evaluation of English-language peer-reviewed literature from 1995 through 2010 indicates that preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure. Benefits include significant reductions in the risk of urinary tract infection in the first year of life and, subsequently, in the risk of heterosexual acquisition of HIV and the transmission of other sexually transmitted infections.

There is no way for these relative inputs to clearly demonstrate the universal conclusion endorsed by either. The AAP and Bering demand too much. And the money quote is not what Bering provides, but instead this quote from the technical report:

… Reasonable people may disagree, however, as to what is in the best interest of any individual patient or how the potential medical benefits and potential medical harms of circumcision should be weighed against each other. …

As I wrote earlier, the highlighted statement is the ethical argument. It demonstrates the flaw in pretending that “preventive health benefits of elective circumcision of male newborns outweigh the risks” is an objective conclusion, or that it justifies proxy consent for non-therapeutic male child circumcision. The AAP Task Force stating its evaluation based on its members’ subjective weighting does not change the ethical and rights violation. Individuals – males, only – should not be forced to live with a permanent, non-therapeutic alteration to their bodies based on their parents’ subjective preferences.

… The more vocal “intactivists,” who’ve long been protesting what they regard as an antiquated, cruel and unnecessary ritual act against little boys that is just as abhorrent as female clitoridectomy, have also responded bitterly to this newest AAP development, seeing fresh strands in an ongoing web of conspiracy between the major health organizations, third-party insurance companies implementing the policy views of these organizations, and greedy practitioners who mislead parents about the benefits of circumcision only to reap insurance payouts for “mutilating” children’s genitals.

Even though there are instances of conspiracy thinking, which are inexcusable, this is a straw man. I quoted the key sentence from the AAP’s policy statement above. There are valid issues involved that do not require conspiracy thinking to reject the AAP’s recommendation. Erecting straw men doesn’t negate those issues. For example, bodily harm, physical integrity, self-determination, and equal protection. Something more than weak caricatures of opposing positions would be useful. Engage in an Ideological Turing Test, at least. That would be respectable, unlike “just watch the reactions to this little essay of mine”.

What is vital to understand about the AAP’s recommendation is that the Academy is not discounting, in any way, the biological purpose or function of foreskin. …

I can’t find anything in either the policy statement or the technical report that discusses the biological purpose or function of the foreskin in a manner suggesting someone might want it. I also won’t ignore the implication throughout that parents should be allowed to discount the foreskin in any way they wish for their son(s). That implication is a critical part of the analysis, since that’s where the AAP and Jesse Bering believe this non-therapeutic, unethical decision may be made.

Within the two columns of one page where the Task Force discusses the foreskin, it pursues only the question of whether sensitivity and/or function are altered. That is different than stating advantages of having a foreskin. The abstract merely states: “Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction.” Within those two columns in the Sexual Function and Penile Sexual Sensitivity section on page 769, the technical report is a bit stronger :

The literature review does not support the belief that male circumcision adversely affects penile sexual function or sensitivity, or sexual satisfaction, regardless of how these factors are defined.

The problem is that the literature doesn’t seem to support the belief that male circumcision does not adversely affect penile sexual function or sensitivity, either. (Circumcision always alters the mechanics of the penis.) From the two “good quality randomized controlled trials that evaluated the effect of adult circumcision on sexual satisfaction and sensitivity in Uganda and Kenya” since 1995, the reports were compelling. Except for the caveats:

… [The Ugandan] study included no measures of time to ejaculation or sensory changes on the penis. In the Kenyan study (which had a nearly identical design and similar results), 64% of circumcised men reported much greater penile sensitivity postcircumcision.127 At the 2-year followup, 55% of circumcised men reported having an easier time reaching orgasm than they had precircumcision, although the findings did not reach statistical significance. The studies’ limitation is that the outcomes of interest were subjective, self-reported measures rather than objective measures.

It doesn’t bother me if a male is happy with being circumcised, even if his parents made his decision in childhood. That doesn’t change the ethical issue. I’m questioning the applicability of these studies on adults to newborns. Those limitations are critical. It’s also hardly compelling to imagine that individual preferences should be ignored in favor of population-based opinions. Within every finding in those two studies, there are males who do not conclude that circumcision is neutral or better for themselves.

From the Sexual Function section:

There is both good and fair evidence that sexual function is not adversely affected in circumcised men compared with uncircumcised men.131,134–136 …

Quoting the the study in footnote 136, “Sensation and sexual arousal in circumcised and uncircumcised men”:

It is possible that the uncircumcised penis is more sensitive due to the presence of additional sensory receptors on the prepuce and frenulum, but this cannot be compared with the absence of such structures in the circumcised penis.

Maybe that should’ve been included in the Sexual Satisfaction and Sensitivity section? To restate the obvious: the foreskin is removed during circumcision. Comparing that in circumcised men is impossible. Or, as the technical report states:

Limitations to consider with respect to this issue include the timing of IELT [intravaginal ejaculation latency time] studies after circumcision, because studies of sexual function at 12 weeks postcircumcision by using IELT measures may not accurately reflect sexual function at a later period. …

Studying whether or not adult circumcision adversely affects sexual sensitivity or function does not necessarily answer the same question for males circumcised as infants.

Back to Bering’s post:

… What the task force has implied, rather, is that whatever the advantages to being an intact male – such as increased sensitivity of the glans, protection, lubrication facilitating better heterosexual intercourse (in addition to the lubricating properties of shed skin cells and oils that accumulate under foreskins, an accentuated coronal ridge may also retract more vaginal fluids during copulative thrusting) – these advantages are overshadowed in importance by the prophylactic benefits of removing highly receptive HIV target cells that are found on the inner mucosal surface of the foreskin. …

Did the Task Force consider any of the advantages Bering listed? I didn’t see any of them stated in the policy statement. That suggests to me that the Task Force discounted the foreskin. They don’t appear to have considered the foreskin in any meaningful way. The recommendation that the benefits outweigh the risks is subjective and lacking in universal applicability. They proved no overshadowing.

To quote Task Force member Douglas Diekema, male circumcision “does have medical benefit. Not everyone would trade that foreskin for that medical benefit.” That seems obvious, especially since it’s implied in the ethical issues section of the technical report. That’s what makes it odd to see the nonsensical declaration in the abstract. And from Bering:

To circumcise, or not to circumcise? To me, at least, that’s no longer even a question. It remains as much a no-brainer as it was when I first wrote about this issue two years ago. If male circumcision reduces the probability of contracting the HIV virus even a fraction of a percent—let alone the estimated 60 percent reduction that scientists believe it does—…

From the technical report:

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.

I’m aware of no studies showing a reduced risk from circumcision for anything other than female-to-male transmission through vaginal intercourse, so that assumption is perhaps reasonable. (The difference in context between the U.S. and the high epidemic in Africa may reduce the number further.) Thus, the 60 percent relative risk is not the correct number. The estimated 15.7% lifetime relative risk reduction becomes a fraction of a percent reduction in absolute risk of heterosexually acquired HIV in the United States.

… then why on earth wouldn’t you choose circumcision? …

Because the healthy child does not need and may not want to be circumcised? Because he still has to wear a condom? Because there are risks and costs from circumcision? Because not everyone would trade that foreskin for that medical benefit? Because all individual tastes and preferences are unique? That’s why on earth parents shouldn’t choose circumcision for their healthy sons.

In the context of the quote that opens this post:

… Have you ever seen a person slowly succumb to AIDS? The pain inherent therein is not even in the same galaxy of subjective experience as whatever minute qualia of pleasure may or may not be lost to such a “mutilation.” The sacrifice is no longer one made to a mythological deity, but to the child himself. HIV is not just an African problem, the logistics apply to any part of the world where the virus is found, …

Do we know the subjective experience difference is a minute qualia of pleasure? Does the child want that sacrifice made to him? He doesn’t need it and has ways to achieve the same benefit in greater measure.

… and circumcision protects against more than this one virus alone. If you want to invest in the probability that your son will grow up to become so unfailingly logical that lust will never, not even once, overcome his level-headedness, and that he will always have both a condom on hand and use it every single time that an opportunity to have intercourse with a potentially infected stranger arises, that’s your prerogative. You’ve probably not interacted with many actual human beings in your life, but, hey, it’s your kid.

I am so unfailingly logical that lust has never, not even once, overcome my level-headedness. I do not want or need that benefit in exchange for my foreskin, yet I no longer have my choice about my body. But, hey, I’m my parents’ kid. My foreskin belonged to them, so why I should I reject their decision about my body?

One can either listen to …, the overwrought intactivists attempting to intimidate new parents through strong rhetoric and graphic images of botched circumcisions, …

What does “Have you ever seen a person slowly succumb to AIDS?” qualify as, if not strong rhetoric?

What was once unquestionably “inhumane” and “unethical” has, oddly enough, made a complete about-face as a consequence of vitally important scientific data emerging over the brief span of two highly productive decades. Yet many parents continue to be emotionally sabotaged by the baby-harming language of intactivists and online blowhards, whose rhetoric primes them to either see these critical developments in conspiratorial terms or to indulge in amateurish debunking of complicated research.

Debunk? I’m not trying to do that. I accept the reality of every potential benefit, without relevant caveats. If nothing else, it’s because I don’t need them. It’s all in the truth that not everyone’s cost-benefit analysis will reach the same conclusion. Parents aren’t psychic for what their sons will want.

But I can read the policy statement abstract, the technical report, and its sources to understand where they don’t quite mesh. They don’t support the sweeping, conclusive statements the AAP makes that Bering endorses.

So here’s one of those rhetorical devices that intactivists should appreciate: Cut it out. For every amazing prepuce you save, you’re adding an element of risk and uncertainty for the person attached to it. Nobody can possibly know what viral foes a man will come up against in his life, and if one of them is HIV, your crusade, admirable though you feel it is, may be costing some other parent their child’s life.

Every circumcision adds an element of risk and uncertainty for the person attached to the foreskin. Nobody can possibly know what viral foes a man will come up against in his life, including his parents. If one of them is HIV, he should be wearing a condom. (And maybe consent to voluntary circumcision as an adult, if he’s inclined.) If he becomes infected, the responsibility rests with him, not me. Not that HIV is automatically fatal anymore. It’s also worth considering the possibility that other solutions may be discovered in the future, and maybe before a child born today becomes sexually active.

The framing of costing a parent their child’s life is bizarre, as if parents own their children. Permitting (and encouraging) non-therapeutic male child circumcision treats parents as the owners of their son’s prepuce, which is odd from a human rights perspective, but also from the reality that parents are legally prohibited from acting as if they own their daughter’s prepuce.