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[ACC] What Are The Benefits, Harms, And Ethics Of Infant Circumcision?

[This is an entry to the 2019 Adversarial Collaboration Contest by Joel P and Missingno]


“They practise circumcision for cleanliness’ sake; for they would rather be clean than more becoming.” – Herodotus, The Histories – 2.37 

The debate over circumcision in the Western world today is surprisingly similar to the conflict that Greeks and Egyptians faced 2500 years ago.  Supporters tend to emphasize its hygiene and health benefits; opponents tend to call it cruel or to emphasize its deviation from the natural human form.  In this adversarial collaboration we address medical aspects, sensitivity and pleasure, and ethical aspects of infant circumcision. 

Effect on penile cancer

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.  Likewise, a Kaiser Permanente study of patients with penile cancer found that 16% of patients with carcinoma in situ had been circumcised; only 2% of patients with invasive penile cancer had been circumcised.  Since the circumcision rate of Kaiser patients of the appropriate age was ~50%, this is in line with the 90% reduction.

While these are observational rather than prospective trials, the magnitude of the reduction is quite high.  It is unlikely to be simply due to class or race given that it exists when comparing countries and when comparing individuals within the same health care system.  Additionally, there is some association of penile cancer with HPV and a very strong association with phimosis, and circumcision reduces the rate of both of these.  This provides a highly plausible theoretical explanation of how circumcision might lead to this risk reduction in penile cancer.  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.

Effect on transmission of HIV and STDs

HIV: Three large randomized control trials have been performed in South Africa, Uganda, and Kenya, together comprising over 11,000 men.  These men were randomized to be circumcised or not at the start of the studies for primary HIV prevention.  The reduction in female to male HIV transmission seen in these studies is about 50%. This is consistent with observational studies and is the highest quality evidence: three independent, large-scale randomized control trials with similar results scrutinized by the Cochrane Collaboration. The studies were terminated early due to positive results, which is appropriate ethical practice, but which can tend to overestimate positive effects.  However, the data is consistent with observational data so this is less likely a concern. Some have expressed the concern that the two groups did not receive identical HIV counseling. 

It is true that the circumcision group felt much more comfortable having sex without condoms, and additional counseling was given to the circumcision group to tell them this was not adequate protection.  Condom use was, despite the counseling, lower in the circumcision group than in the control. In one sense this means that the protective benefits of circumcision vs HIV may be understated. In another sense, this creates a large concern with advertising circumcision for the stated purpose of HIV prevention.  Any such efforts must be careful not to oversell the benefits and thereby reduce condom usage. Additionally, the results are only applicable to heterosexual HIV transmission. Homosexual transmission has not been shown to be decreased by circumcision, presumably because of the extremely high risk of receptive anal sex.  IV drug related transmission is almost certainly unaffected except via “herd immunity”.

The data for other STIs is far less compelling than for HIV. Secondary endpoints of the African HIV studies were other STIs, and rates of HPV and HSV were reduced by circumcision. This was only a secondary outcome, however, and other studies have had mixed results. The data for lower rates of bacterial vaginosis and trichomonas in female partners of circumcised men is somewhat stronger. However, none of these benefits are nearly as strongly supported or as high impact as the HIV reduction.  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.

It is ironic that the evidence for reduction in other STIs is fairly weak, because as historian David Gollaher shows in Circumcision: A History of the World’s Most Controversial Surgery, this is the primary reason the US adopted widespread circumcision in the early 20th century.  There had been very small-scale interest in circumcision due to religious ideas about masturbation and ideas about balanitis and phimosis causing systemic illness, but these ideas do not appear to have motivated a large number of circumcisions. Mainstream circumcision of healthy males caught on as a way to reduce STI rates – particularly syphilis. Physicians both in the US and UK saw the far lower rates of STIs Jews experienced than gentiles and attributed these primarily to circumcision. In the US, the time was just right for such STI reduction efforts – worries about infection were widespread and an increasing number of people were adopting hospital births where there was ready access to a physician able to perform a circumcision.

Meanwhile, during WWI and WWII the military offered circumcision to many conscripts to protect vs STIs (the wealthier officer class already having a much higher circumcision rate than the enlisted men as more of their parents could afford hospital births). The UK’s experience of WWI and WWII was quite different from the US’s. For one thing, STIs ranked far lower on the set of risks to soldiers. And rather than seeing a boom in hospital births, the UK’s medical resources were strained during WWI and WWII. Circumcision was seen as something of a waste compared to the UK’s more pressing needs. Presumably, arguments that positively presented Jews as having low STI rates did not catch on in early 20th century mainland Europe to nearly the extent that was seen in the US and UK.

Effect on UTIs

In the first year of life, the rate of UTIs is approximately 1% per year among uncircumcised boys and 0.1%-0.2% among circumcised boys.  Particularly in the first year of life, UTIs can be severe, causing fever and hospitalization, as well as permanent kidney damage. Circumcision is presumably protective against UTI primarily by reducing the bacterial load around the urethra. Some sources have suggested that the difference is primarily one of contamination during sampling. However, studies looking only at clean catch urine samples or suprapubic tap samples give similar reductions (90%). Unlike many of the other benefits listed above, UTI avoidance is specifically a benefit of infant circumcision.

Effect on Penile Problems

Many penile problems such as balanitis (inflammation of the glans), pathologic phimosis (inability to retract the foreskin), and paraphimosis (foreskin entrapment, which requires emergency treatment to preserve the penis) are prevented by circumcision.  Others, including meatal stenosis, scarring, bleeding are caused by circumcision. A New Zealand cohort study directly comparing the incidence of penile problems requiring intervention found a rate of 1.1% in circumcised children and 1.8% in uncircumcised children when followed to age 8. 

Risks of surgery

The risks of surgery include pain, bleeding, bruising, inadequate foreskin removal, excess skin removal, swelling, meatal stenosis, scarring, infection, and anesthetic complications. These are different based on age group; neonatal circumcision is associated with a much lower risk of complications than other age groups.  However, studies show a wide range of rates of complications dependent on practitioner training level. Overall, the rate of minor complications (bleeding, bruising) is ~1.5% worldwide and the rate of major complications (scar, severe infection, meatal stenosis, or need for additional surgery) is <0.2%.  In comparison, the risk of complications in children past infancy and adults is approximately 6% with trained practitioners – significantly higher than for infant circumcision.  Indeed, the majority of cases of the most severe complication (penectomy) related to circumcision appear to occur in people who were not circumcised as infants.  This would include both adults with penile cancer as well as children undergoing phimosis surgery (as in the infamous case of David Reimer).  

Sensitivity and Sexual satisfaction

There is a highly plausible mechanism by which circumcision could reduce sexual sensitivity: the foreskin is highly innervated (20,000 nerve endings is often repeated, but this appears to be a case of citogenesis and is likely far too high), produces lubrication for the penis, and is sensitive to light touch. Several studies demonstrate that the foreskin is more sensitive to certain forms of nonsexual stimulation than other parts of the penis. The glans itself does not change in sensitivity from circumcision. 

Sexual satisfaction, particularly in sexually active heterosexual men, seems to be unchanged with adult circumcision.  During studies of adult circumcision for HIV prevention, in which large numbers of men were randomized to receive circumcision at the time of the study or after, sexual satisfaction of did not significantly differ between the two groups.  On the other hand, a South Korean study of men circumcised as adults (as has become traditional there) found decreased pleasure from masturbation after circumcision.  It is certainly possible that both these things are true – that masturbation is impaired by adult circumcision while intercourse is not.  It is also possible that the Korean study (retrospective, smaller than the African studies, and with much higher rates of scarring than are observed in the US) was unrepresentative.  There are two European studies which are frequently cited: cohort studies look at circumcised and uncircumcised men in Denmark and Belgium. However, circumcision is quite rare in these countries, and the majority of the circumcisions in the study groups were performed to correct problems such as phimosis. They are thus comparing men who had penile problems requiring surgical correction to men who did not; it is therefore unclear why they are frequently cited in discussions of elective circumcision.

No available studies actually measure sensitivity to sexual stimulation, which is of course an important topic – but one requiring consummate professionalism on the part of the researcher.  We are left waiting for such a study, but in the meantime may reasonably fear that there is some decrease in at least masturbatory pleasure due to circumcision even though the evidence for this is weak. The evidence does not support any change in sexual pleasure otherwise. 

Infant circumcision may be different than adult circumcision, in addition.  If circumcision eliminates important nerves, due to brain plasticity infants are likely better able than adults to reassign the portions of the brain processing the foreskin to other areas of the penis.  A large survey of circumcised and uncircumcised men in the US (where infant circumcision is the most common) found similar sensation in circumcised and uncircumcised men. The uncircumcised men appear to have had slightly higher incidences of sexual dysfunction. Also of interest, circumcised men appear to have an easier time obtaining oral sex, which may relate to subtle aspects of class or may have to do with the perceived cleanliness of circumcised penis.

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.

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466 Responses to [ACC] What Are The Benefits, Harms, And Ethics Of Infant Circumcision?

  1. graehl says:

    -1 not quantifying the likelihood of *needing* an adult circumcision
    -1 not giving base rates for penile cancer and AIDS
    -1 NZ ‘penis problems’ study abstract says 11.1 problems per 100 vs 18.8 per 100. but authors above say 1.1% and 1.8%
    -1 useless discussion of “if people think something helps they might not use condoms”
    -1 acting like survey answers about sensation from different people can be compared (as opposed to feedback about before/after adult circumcision)

    Otherwise a good effort.

    • inhibition-stabilized says:

      -1 useless discussion of “if people think something helps they might not use condoms”

      Far from being useless, I think when proposing a policy for society at large it’s always a good idea to consider unintended consequences like this. This is nowhere near my field, and from what I can tell the research on risk compensation seems to be pretty controversial (and would probably take its own post to sort out), but simply ignoring the possibility seems a bit reckless.

    • algorizmi says:

      Regarding sensation, this collaboration omits the most objectively quantitative study to date. Fine-touch pressure thresholds in the adult penis. (2007)

      Also no direct Number Needed to Treat or cost for either the procedure itself or any harms caused or prevented. So incomplete even from a utilitarian perspective, let alone the minimal ethics section for a topic of this title.

      Worth noting that preadolescent phimosis is over/misdiagnosed.

      • Radu Floricica says:

        It might help a lot if collaborations could be re-published after the initial round of feedback. Two people in a few months can do quite a lot, but it’d be a shame not to have a final form that benefits from the community input as well.

        • Watchman says:

          Is there a case for there being a competition draft, and then the authors having the option of publishing a final draft on the basis of what is effectively peer review (if your peers are SSC readers…) on a massive scale? It would be nice to be able publish things on a final form once feedback is received, and it would be an interesting test of the dynamics of adversarial collaboration to see how the adversarial authors react to external comment.

      • algorizmi says:

        Also: The cost-benefit for HIV is substantially less compelling in first-world countries, infant UTIs are not associated with functional sequelae, and expect penile cancer incidence to drop 50-80% anyway for HPV vaccinated cohorts.

        https://www.cps.ca/en/documents/position/circumcision

        • Robert Jones says:

          This to me is the important point. The question as phrased is abstract (“Is infant circumcision ethical?”), but the answer may plausibly depend on circumstances. The benefit of circumcision in reducing HIV infection rates via vaginal intercourse depends on the base rate for that risk, which (for reasons I don’t understand) varies significantly between countries.

          This seems to me to be crucial, because the penile problems are basically a wash and UTIs are not that big a deal, so to my mind that the decrease in masturbatory pleasure carries it (even if uncertain) even if we don’t assign a utilitarian benefit to maintaining the principle of bodily autonomy (which we probably should).

      • Peter Gerdes says:

        Don’t really see relevance of this as the harm we are interested in worse sexual pleasure and it’s not immediately obvious how this relates to sensitivity.

    • RGTP_314 says:

      acting like survey answers about sensation from different people can be compared

      Of course they can. Between subjects designs are totally legitimate even when the DV is a measurement of subjective states. Although the error in measurement is non-trivial, it tends to be normally distributed and, therefore, mitigated by random sampling.

      • Peter Gerdes says:

        Only if their status doesn’t affect how they answer. I worry that people report level of sensation based on their conception of the societal range of variation, eg, if I have the worst pain I’d ever experienced I won’t say it’s a 10 on pain scale because I’ve heard of bone cancer.

        This is a problem when it comes to rating how sensitive your dick is since the perception it’s better for uncircumcised ruins the independence assumption.

      • The survey question that might get a more objective answer is length of time between commencement of intercourse and orgasm. Time is objective, although there might be measurement errors.

        And I would expect that greater sensitivity would lead to shorter time.

        • Aapje says:

          We need volunteers with stop-watches to time people. Supposedly there is a community with a lot of polyamorous people where this might be done 😛

  2. hnau says:

    I appreciate how this collaboration arrives at a well-cited and authoritative-sounding set of facts, but overall I was disappointed. Main reasons:
    – Chosen issue isn’t particularly high-stakes or controversial, so the adversarial aspect has less benefit
    – Write-up reads like a committee report rather than a Much More Than You Wanted To Know
    – Facts / statistics / considerations are never really put in context; I don’t have a sense of why / how people might disagree on this, or what the authors consider to be the most important points of contention

    I rate this collaboration as a 5/10 (no particular scale or judgment implied, this is just for my own reference). As always, many thanks to the authors for putting in the work to create this.

    • The Pachyderminator says:

      Chosen issue isn’t particularly high-stakes or controversial

      As always, that depends entirely on what bubbles you live in. There are forums where the entire topic of circumcision is banned because it’s just too inflammatory. (One that I know of is populated mainly by mothers, not men.)

    • Scott Alexander says:

      I was actually pretty impressed by it. I had kind of swallowed the popular consensus that circumcision was Useless And Evil, and this gave pretty strong evidence that it has a variety of medical benefits and there’s no clear evidence it has any harms (especially reducing sexual pleasure, which is the main harm I’d heard cited). It seems to say that it’s hard to be against circumcision on anything other than a sort of deontological/autonomyesque/precautionary principle, which is not at all what I was expecting.

      • acymetric says:

        Speaking of bubbles…are you sure that is actually “popular consensus”? Evidence would suggest pretty strongly that it isn’t.

        • Radu Floricica says:

          If another datapoint helps, I had the exact same reaction to the article as Scott.

          Also, the chosen issue is pretty controversial, especially when somebody that regrets having been circumcised enters the conversation.

        • edanm says:

          Well it definitely depends on the bubble you’re in, but as another datapoint, I’m an Israeli (in which a majority of the population is circumcised), and this topic comes up once in a while in Facebook threads here, and there’s certainly a strong component of people who are absolutely against it. There’s also some people feeling that circumcision will in 50 years be considered barbaric and no one will do it anymore. Of course, I live in Tel Aviv (very liberal) and hang out in rationality forums so you can imagine what kind of people are in my Facebook feed.

          (Fwiw, I don’t think it’s such an important issue, and largely disagree with people who think it will become much less commonplace here in the future.)

          • Jon S says:

            The majority of the (male) population is circumcised in the US too.

          • spencer says:

            I wonder how much of that sentiment comes from the association between circumcision and religion (especially in Israel, but also in the US I think). Perhaps there’s a tenancy for atheists/secularists to oppose circumcision just because the Torah requires it?

      • hls2003 says:

        Not to be critical, but I would have thought a medical doctor would not have had that perspective; the American Academy of Pediatrics consensus policy is that the procedure has benefits, and that the benefits outweigh the risks, but not strongly enough to actively recommend universal circumcision, instead leaving it up to the parents. This literature review seemed pretty much in that basket.

        Anecdote: at one of our birthing classes, a question was asked about circumcision by one of the participants. The nurse gave the standard answer (the AAP has found that the benefits outweigh the risks but it is the parent’s decision) and the parent-to-be (who obviously hewed closer to the idea you are describing) digested that for a moment, then said “OK, uh, are there any other pediatric associations I could ask?” My wife and I almost laughed out loud at the unspoken “Any other [less reputable] pediatric associations that [will tell me what I want to hear]?”

        • JohnBuridan says:

          Also, since it wasn’t mentioned in the article, circumcision is performed within a few hours of birth and is only given (in our hospital) if the child receives a Vitamin K shot prior in order to stimulate blood coagulation.

          Disturbing practice about post-circumcision from our birthing class: when changing the diaper for the first couple weeks one is supposed to scrunch down the remaining foreskin of baby to ensure the “hood” does not grow back. I think this is might the rock the scales in some people’s minds about how weird this practice really is.

          • hls2003 says:

            On the sheath cleaning, the advice we got at our birthing class was that you were supposed to do that same basic thing whether circumcised or not; for circumcised boys to avoid any scab sticking, for uncircumcised boys the whole foreskin to allow for cleaning and avoid bacterial buildup. I guess I didn’t see that as weird either way.

          • Watchman says:

            Interesting. I haven’t (having had two boys and attended relevant classes for both) heard this, but I live in the UK where circumcision is almost entirely religious or medical. I could hypothesis that the benefit of cleaning the foreskin in this way is a post-hoc rationalisation of a practice adopted for the purpose of healthy circumcision, as one area where I am happy with the UK NHS is the advice you get about babies (basically you get enough to make your own call). If washing the foreskin was necessary for neonates then I’m pretty certain we’d have been told by someone. General advice is to clean if dirty (obviously) but otherwise to just wash normally.

            Interestingly (not causal, questionable correlated) the UK has notably lower neonatal mortality than the US. I’m guessing size and scale are perhaps bigger issues here though.

        • Space Ghost says:

          > I would have thought a medical doctor would not have had that perspective; the American Academy of Pediatrics consensus policy

          The AAP is a membership organization and not an “official” or governmental body, so it’s not really reasonable to expect a non-pediatrician to be familiar with all of their positions. Furthermore the AAP actually does not have a current policy on circumcision – statements expire after 5 years unless reaffirmed or revised and I don’t see any evidence they have done so. The most recent one is from 2012, so it’s expired: https://pediatrics.aappublications.org/content/130/3/585

          • hls2003 says:

            I see no evidence they’ve changed their position, either. I don’t think the “non-governmental, membership” thing is relevant – I presume Scott would take the American Psychiatric Association’s opinion into account in considering the baseline position in his own area.

            Fair enough that it’s not his area, but I would expect a doctor’s initial response to be “what does the relevant medical specialty say about this?” Not saying he can’t form his opinion from there, but I’d think it would be a normal starting point.

        • viVI_IViv says:

          the American Academy of Pediatrics consensus policy is that the procedure has benefits, and that the benefits outweigh the risks, but not strongly enough to actively recommend universal circumcision, instead leaving it up to the parents.

          Seems to be an American thing. According to Wikipedia:
          “The positions of the world’s major medical organizations range from considering elective circumcision of babies and children as having no benefit and significant risks, to the procedure having a modest health benefit that outweighs small risks.[7] No major medical organization recommends either universal circumcision of all males or banning the procedure.[7]”

          • meh says:

            The WHO makes a decidedly non american recommendation.

            WHO/UNAIDS recommendations emphasize that male circumcision should be considered an efficacious intervention for HIV prevention in countries and regions with heterosexual epidemics, high HIV and low male circumcision prevalence.

        • Peter Gerdes says:

          Your misreading the comment. He is just saying he is surprised that there wasn’t good reason to think circumcision was quite harmful.

          Second, I think it’s clear enough from Scott’s other posts why one wouldn’t take the lack of a rec to do something from a medical body as strong reason to believe the evidence isn’t there. There are all sorts of strong cultural and traditional reasons for the pediatricians not to say everyone should or shouldn’t circumcisce.


          Also, standard for a medical body to recommend something is obviously higher than a preponderance of the evidence that it is a net positive relative to a certain common value scheme. If not it wouldn’t even make sense to have a conclusion of “seems likely on net more benefit than harm but we don’t recommend either way.”. This norm reflects the fact that an official position tends to put pressure on people that might not be appropriate if we are really unsure.

          When Scott expressed his opinion on this blog he isnt dispensing medical advice just sharing his personal view and as such it is totally reasonable for him to say (though not how I read him here) he thinks something is probably a good idea even when his knowledge level or confidence doesn’t rise to the level appropriate to give a formal medical recommendation.

        • marioness says:

          Pediatric associations that do not share the AAP consensus are not less reputable by default. A direct reply addressing AAP’s weaknesses was issued by European leading academic pediatricians (https://pediatrics.aappublications.org/content/131/4/796). This commentary was directed only towards the medical reasons cited by AAP, without even touching the ethical issues. If “health advantages” are to be the justification of such procedure, then the argument should not be whether circumcision can prevent disease, but how disease can best be prevented, as the European reply paper (and common sense) state.

      • aristides says:

        Seconded. I had swallowed the religious consensus that circumcision was Useless, but Good. This put me in an odd spot of feeling guilty for my religious beliefs, and not sure what I was going to do with my own children. I had expected pro-circumcision to be the more deontological side, and never guessed that utilitarian beliefs to suggest being pro-circumcision. I’m giving this high marks, just because it might have persuaded me to change a practice, which none of the old adversarial collaborations were able to do. Going from a guilty and tentative pro, to a full pro is impressive.

      • Jacobethan says:

        Would it be fair to paraphrase this response as saying that it’s a strong paper qua paper, but not necessarily a good representative of the adversarial collaboration genre?

        It seems like the things you liked about it would’ve been the same had it been simply a blog post by a pro-circumcision researcher that you happened to find especially thorough and persuasive. I agree that it works well at that level — which is great! — but also with others that there seems to be relatively little value added by any specifically AdCollab-type elements. (With the exception of the argument’s credibility being perhaps heightened by having theoretically had to pass muster with an anti-circumcision referee.)

      • truthlizard says:

        I agree with hnau that the authors do not succeed in putting facts into context and establishing the most important points of contention.

        The article on Evidence Based Birth reads more like a Much More Than You Wanted to Know. I recommend it for a very thorough analysis of all available evidence for and against circumcision.

        https://evidencebasedbirth.com/evidence-and-ethics-on-circumcision/

    • EchoChaos says:

      – Chosen issue isn’t particularly high-stakes or controversial, so the adversarial aspect has less benefit

      This very comment section definitely belies that.

      Men are understandably very invested in their penises.

    • Etoile says:

      It’s high-stakes if you’re having a baby boy and one of you is pro- and one anti-circumcision! As the collaboration above said, just doing it later if needed isn’t super-easy and riskier than doing it as an infant.

  3. Michael Watts says:

    The ethics of infant circumcision is a complex topic, and the answers likely depend on one’s ethical system.

    Surely the answers to any question of “the ethics of X” must always depend on one’s ethical system?

    • hnau says:

      Yep, bland topic sentence is bland. But to the authors’ credit they go on to explain specifically how it depends on one’s ethical system. Those who highly value autonomy as an end in itself, even in edge cases like child medical care, could consistently consider infant circumcision unethical despite agreeing that it’s mostly beneficial.

      • Don_Flamingo says:

        Personally, I find any value system that doesn’t highly value individual autonomy as an end in itself to be a dire threat to society. And I appreciate that it’s at least mentioned that such values exist and are something people hold quite dear. It should be mentioned.

        It’s also very difficult, if not inappropriate to weave in a meta-argument to the question at hand because from an autonomy-standpoint circumcision would have to give you extreme, obvious and unambiguous advantages to even be considered compromising a fundamental value.
        If you have to ask whether circumcision is worth it, the answer is obviously going to be no.

        The High Rationalist/episteme/top men-perpsective often just assumes that all questions can be answered with oversimplified utilitarianism. They can of course, but the answers will tell you less than you need to know.

        I came to the conclusion that one can make a half- decent utilitarian argument for the pro-side and there appear to be very real, if minor health benefits at perhaps a reasonable cost. It’s a good piece and I updated my beliefs.
        However for me this is completely orthogonal to the question of: “Should we do this?” to which my answer would be an unambiguous and horrified “No. No! Fuck no!” and “Are you literally insane?!”.

        • Purplehermann says:

          “Any value system that doesn’t highly value individual autonomy as an end in itself to be a dire threat to society”

          Is kind of a silly thing to say in the context of parents making medical decisions for their infant children.

          • Don_Flamingo says:

            It worries me not when parents make this decision for their children or when it’s for religious reasons, but when it’s lauded from on high and propagated and promoted as policy. And where it becomes a de facto norm without any personal or religious motivation by the parents. Perhaps this isn’t easy to tease apart where that precisely begins or ends, but the US-case where it’s promoted in the medical system as the default under a Public Health rationale creeps me out.

            edit: Though you’re right. I’m not so much worried about individual rights, that was perhaps misstated. I’m worried about bureaucracies promoting an initimate life decision. I’d prefer them to stay out of the bedroom and away from baby genitalia.

          • Purplehermann says:

            Fascinating.
            What do you think the medical establishment should do when it comes to positive practices?

            Leave the norms to develop naturally?
            Fight any norms existing at all?
            Hide the information (or at least don’t talk about it too loudly)?

            Do you feel the same for all practices and norms, or are medical/invasive/permanent ones much worse?

            What do you think about vaccinations?
            What about other hypothetical procedures essentially identical to circumcision except with less drawbacks and much much larger positive effects?

          • Aftagley says:

            Doesn’t:

            It worries me not when parents make this decision for their children or when it’s for religious reasons,

            Conflict with:

            [it worries me] when it’s lauded from on high

          • Don_Flamingo says:

            @Aftagley
            Yes, parents are “higher” than children, but they’re close to the problem at hand, have aligned interests and are heavily invested [skin in the game and all that].
            I’m worried about decision makers in even loftier heights, who only have fuzzy notions of what the ground is, don’t necessarily have aligned interests and dismiss the local’s preferences. And are not paying a price, if their decisions turn out bad.

            Even assuming angels in charge, I would still hold it with the precautionary principle in regards to such angelic interventions. Because they usually do more harm than good, because of the inherent information assymetry.
            https://en.wikipedia.org/wiki/The_Use_of_Knowledge_in_Society

            @Purplehermann
            Assume we knnow with certainty now that circumcision is on the margin a positive practice. It’s slightly better than the alternative*. The US institutional practice is much older than that knowledge and hardly was acting rationally by providing everyone with an obvious and great benefit. If circumcision was slightly worse or even moderately worse, they wouldn’t have been able to know that for a very long time.

            Vaccinations create obvious and great benefits. And the cost of getting pricked by a needle and going thru an alterative, often painful surgery of genitalia does not compare. It doesn’t need a “medical establishment” to stand behind it. It’s a competetive idea.

            re: leave the norms to develop naturally
            Yes, but don’t mistake that for disinterest in the outcomes! Quite the contrary.

            “What the medical establishment” should do is not act as a centralized authority. The very idea that you can analyze & debate a best practice and then decide on national mandatory norms is on it’s face absurd.
            That’s just not how the world works.
            That’s not….. how the math works.
            How can the best solutions be found, if the search space is constrained early? How can new knowledge be discovered at the lower levels (of individual practices) if constant experimentation and a diversity of approaches isn’t an inherent part of the practice?
            I am not okay with the fact that medical professionals have captured the governement long ago and established themselves as the only guild.
            In the US they even have their own occult hazing rituals where they force residents be sleep deprived over years, whilst making life & death decisions over the outsiders under their knives and care.
            The question where a patient reluctant about embracing circumcision asking for another “pediatric organisation’s recommendation”, which was so sneered at, shows that some people here don’t grok what a cartel is, when it’s staring them into the face.

            I do not think it could possibly be ethical to leave something so high-stakes and so incredibly important as medicine away from free competition and leave it it dependent on capricious status games amongst bureaucrats, a medical profession with a vested interest in keeping out outsiders to keep it’s prices high (pretty much exactly like a medieval guild) and politicians.

            *though people here are vehemently objecting to even that case in the comments, let’s just assume it was uncontroversially good from a naive consequentialist standpoint

        • aristides says:

          @Don_Flamingo
          Most of the Pro circumcision side just wants the bureaucracy to stay out of it as well. The fear is not that OBGYNs will stop recommending circumcision, the fear is that the government will throw you in jail for child abuse, and you’ll lose all parental rights if you do circumcise your child. America probably goes to far in one direction, but Iceland nearly went way too far in the other direction. If the government stays out of it, that’s fine with me.

          • Don_Flamingo says:

            I suppose, I’m not on the anti-circumcision side, per se. I don’t consider it a crime, though in some cases I could consider it being “unfortunate” perhaps.
            And yeah, I see that it’s also a cultural practice, that should not be infringed upon from outside (nor should it be promoted). Admittedly a murky position in practice.
            I have a strong preference against it and my future children having it done to them. But I am quite fanatical in my decentralist beliefs.

            Sorry, I didn’t mean to do some massive bait & switch, to change the topic.
            It’s just that I usually only know what I really believe after I type it out and have it argued against 🙁

          • eric23 says:

            It is also hard to separate the question from the anti-Muslim (and to a lesser extent anti-Jewish) attitudes that are rising in popularity in Europe just as its tolerance for circumcision is dropping. Could be coincidence, but it’s suspicious…

    • sty_silver says:

      Sure, technically every such question depends on the ethical system. But there are cases where the answer stays the same across most ethical systems that are actually popular, and cases where it does not. So it kinda feels to me like you’re just taking it too literally.

  4. kipling_sapling says:

    This has moved me from mostly indifferent (opposed to a societal ban but mildly opposed to having my own future children circumcised) to strongly in favor. It seems like circumcision is a net benefit, however small, for a whole bundle of health concerns with few drawbacks. Thanks for the effort. I’d like to hear from the authors on what they each changed their minds about and what surprised them along the way.

    • Aftagley says:

      +1

      This also changed my mind from not really having an opinion to being in support.

    • RLM says:

      Please, before you become “strongly in favor” of circumcising your own future children based (apparently solely) on this document, take a look at the ethical analysis below by Brian Earp, who is Associate Director of the Yale-Hastings Program in Ethics and Health Policy at Yale University and who focuses on the ethics of circumcision. As many others here have pointed out, the anti-circumcision position here is very weak, it leaves out important information and doesn’t properly address the ethical issues. These resources can provide you a more accurate view and do what this paper should have done:

      Overview of Circumcision (which is what I think a more complete version of this AC would look like): https://evidencebasedbirth.com/evidence-and-ethics-on-circumcision/

      Video lecture by Brian Earp: https://www.youtube.com/watch?v=SB-2aQoTQeA

      Essay by Brian Earp: https://www.researchgate.net/publication/316527603_Cultural_bias_in_American_medicine_the_case_of_infant_male_circumcision

      • take a look at the ethical analysis below by Brian Earp, who is Associate Director of the Yale-Hastings Program in Ethics and Health Policy at Yale University

        At a considerable tangent, how many people here take the fact that a conclusion on a moral issue is supported by someone with academic credentials in philosophy as significant evidence that it is true?

        I expect to learn things about medical issues from medical professionals. I don’t expect to learn things about morality from philosophers.

        • DeWitt says:

          Did you actually read the article?

        • cuke says:

          I can’t tell if you’re being facetious in asking this question.

          The paper by Brian Earp (the third link above) is an analysis of potential bias in the AAP’s 2012 pro-circumcision stance. It’s not a conclusion on a moral issue and any truth claims made in the paper — from my reading — are not about the morality of circumcision but about sources of potential bias in AAP’s recommendation.

          I would liken this essay more to ones written describing the non-scientific, political aspects of the process involved in the APA subcommittee developing the PTSD diagnosis for the DSM. In that sense, it strikes me as helpful in contextualizing the science and identifying factors that may distort presentation of the science in a way that may be invisible to clinicians and patients as they face medical decisions.

          Earp’s analysis seems like an entirely appropriate thing for someone of his credentials to provide. He’s not giving moral advice about whether or not to circumcise one’s child.

        • broblawsky says:

          Then where do you expect to learn things about morality?

        • Ttar says:

          As others have said, this is a weird non sequitur. But even if it weren’t… From a Bayesian perspective, would you expect to find a moral argument from a highly accredited philosopher/ethicist more or less useful to you than one from e.g. a pizza delivery person? If I’m looking for a needle, I’ll open a sewing kit before looking in a haystack. At worst, the accreditation is very low value. But at least it implies the person can argue coherently.

        • NoRandomWalk says:

          I mean, there are so many more philosophies than philosophical truths, but I’ve gotten very little insight from philosophers and almost no insight from non-philosophers. Big advantage: philosophers.

          For example, hume’s problem of induction was pretty mindblowing to me. Once I understood that I only believe on causality on faith I went into ‘do only what u want state’ for a couple weeks (mostly sleep a lot, don’t do your homework or anything stressful; did wonders for my health, eventually snapped out of it). I don’t think a secular conversation ever had a significant effect on me in real-time. It’s always a small new interesting point, to reflect on and integrate slowly later.

        • sty_silver says:

          I think it’s a perfectly fine question. Knowing how you would answer it is pretty important for navigating the world.

          I don’t. The fact that someone is a professor of any kind makes me take them more seriously, but not by much. Not nearly enough that I would consider their opinion a strong data point.

          As for the field, I would probably assign a math professor’s opinion on ethics more weight than that of someone in philsophy.

          • I learned something important and relevant to ethics from a philosophy professor once, about fifty-five years ago.

            I didn’t read the article. My point was not about the article but about academic philosophy.

        • RLM says:

          @DavidFriedman, I would like to draw your attention to Brian Earp’s recent comment on this article.

      • eric23 says:

        I would like to see an adversarial collaboration with this guy, but I wouldn’t accept his opinion alone as being particularly objective.

      • NoRandomWalk says:

        @RLM +100. I found your link quite informative/useful corrective.

      • zzzzort says:

        Arguments about circumcision aside, it really annoys me when people define ‘the rest of the world’ as western europe and canada. Besides ignoring the majority of the world, there’s a tendency to define the norm by what the most countries do, when the practices of western europe are far from independent, and the total population combined is about the same as the US.

  5. cvxxcvcxbxvcbx says:

    I consider my mutilation as an infant to be rape, and I will never forgive my parents or the society that allowed it.

    • Evan Þ says:

      In contrast, I consider my circumcision as an infant a point of very minor relevance; this essay changed my position from not really caring to being mildly glad my parents had it done for me.

    • Logan says:

      Your experience is your own (and I’m very sorry that happened to you), but mine is very different.

      As a Jew, if I had not been circumcised as an infant, I would have considered it a theft of my birthright and a destruction of my cultural identity. The Nazis forced Jews to be tattooed because tattoos are forbidden by the Torah, it was an attempt to defile their bodies and degrade their culture; a legal ban on circumcision would be similar in effect.

      My only concern in this discussion is to argue against what I see as growing support for a legal ban. Lots of people who have strong negative experiences around circumcision sometimes forget that theirs is not the only important perspective.

      • An Fírinne says:

        Nobody is stopping you or anybody from getting circumcised. I don’t think anybody here would call for a ban on adult circumcision, its involuntary child genital mutilation thats the problem.

        • Purplehermann says:

          In jewish culture child circumcision is the optimal way to go (from a cultural standpoint), banning it would bother religious jews badly enough that they would largely work around the law or leave the country.
          It would bother Logan (same goes for me btw) to not have been circumcised as a child.

          I’m not sure why you think it is so horrible to make a smart medical decision for your child as a secular parent.

          • An Fírinne says:

            In jewish culture child circumcision is the optimal way to go (from a cultural standpoint), banning it would bother religious jews badly enough that they would largely work around the law or leave the country.

            In all honesty I think I can live with that.

            I’m not sure why you think it is so horrible to make a smart medical decision for your child as a secular parent.

            Because I believe in bodily autonomy. Regardless the jewish way of doing it is quite barbaric. Its not like going to a hospital to get a medical procedure done. Its a very nasty practice as done in its present form.

          • C. Y. Hollander says:

            Regardless the jewish way of doing it is quite barbaric. Its not like going to a hospital to get a medical procedure done. Its a very nasty practice as done in its present form.

            What exactly do you know about it? It seems to me that “barbaric” means just the same thing to you as it did to the ancient Greeks: belonging to a culture that is not yours and which you therefore look down upon. For your information, there is nothing cruel or nasty about the “Jewish way of doing” circumcision. It’s a swift operation performed with an extremely sharp knife and to all appearances the infant has forgotten it moments later.

            In jewish culture child circumcision is the optimal way to go (from a cultural standpoint), banning it would bother religious jews badly enough that they would largely work around the law or leave the country.

            In all honesty I think I can live with that.

            Frankly, this is is rather suggestive as to how you feel about religious Jews. Perhaps your aversion to them is what leads you to form ignorant opinions about their practices.

          • viVI_IViv says:

            For your information, there is nothing cruel or nasty about the “Jewish way of doing” circumcision. It’s a swift operation performed with an extremely sharp knife and to all appearances the infant has forgotten it moments later.

            It’s performed without anesthesia in a non-sterile environment by a person who is usually not a trained medical professional. The Haredim even have the Rabbi suck the blood out of the wound with his mouth, which poses a severe health risk.

        • Nick says:

          Yeah, I’m confident you have no problems at all with circumcision, which is why you call it genital mutilation.

          Retracted, uncharitable.

          • Randy M says:

            Nick, I don’t think this is fair. An Fírinne doesn’t say or imply he has no problems with it, rather that he wouldn’t limit the procedure if done voluntarily.

          • An Fírinne doesn’t say or imply he has no problems with it, rather that he wouldn’t limit the procedure if done voluntarily.

            If done voluntarily by adults. But everyone seems to agree that if it is to be done, it is much less risky when done to infants.

            He also says or implies that he doesn’t mind if a ban on infant circumcision causes lots of Jews to leave the country.

          • Randy M says:

            If done voluntarily by adults.

            Given the difficulties in getting consent from an infant, I feel this was understood without being explicit.

      • Loris says:

        The Nazis forced Jews to be tattooed because tattoos are forbidden by the Torah, it was an attempt to defile their bodies and degrade their culture[…]

        I was surprised by this claim, and don’t think it’s true.

        I had always assumed the Nazi-enforced tattoos I was aware of – numbers on the forearm – were there for identification purposes. This wikipedia article seems to agree.

        If the objective were to defile, as you suggest, much more effective forms could have been used.

        So I am interested in how you come to that conclusion.
        Do you have any evidence for your claim? Perhaps it is another form of Nazi tattoo you’re thinking of?

    • Don_Flamingo says:

      Being uncircumcised myself as that is just “not a thing” in Germany and find the very idea recoiling, I nevertheless think your reaction against your parents and society is unjustified and immature.
      (unless your circumcision was botched somehow and you were literally left mutilated, then I could understand the resentment against your society)

      • dionisos says:

        I don’t see why it is unjustified or immature.

        • onyomi says:

          Yeah, I actually find the above comment representative of the kinds of social pressures militating against men admitting circumcision bothers them even if it does. We have a man who wasn’t circumcised himself, who finds the idea “recoiling,” and who nevertheless describes someone who feels traumatized about having had something “recoiling” done to him “immature.”

          Men who talk about or don’t minimize their “scars,” literal and metaphorical, are viewed as whiners, weaklings, malcontents, immature, etc. One can imagine all kinds of historical and evolutionary reasons this might be the case; though that doesn’t make it right, either.

          • dionisos says:

            Yes, thanks to express almost exactly my though 🙂 (I should admit I was too lazy to do it here ^^)

          • Aapje says:

            @onyomi

            Indeed. All evidence for a lack of male suffering should be regarded wearily, IMO, given how strong this norm/bias is.

            Note that there also seems to be a feedback-loop: the very fact that men rarely complain is taken as strong evidence for the issue to be minor, which is taken as evidence that complaining men are complaining about minor or even non-existing things, which prevents men from complaining.

            I believe that in SJ, this is called the dismissal of the lived experience of the oppressed, where oppressive gender norms result in people dismissing the severity or even occurrence of lived experiences.

            Furthermore, due to internalized misandry, men may themselves not see their problems as being severe and may actually participate in the oppression of other men.

    • meh says:

      you’re not gonna want to know how they took your temperature.

      seriously though, if it makes you feel better, they were probably trying their best

    • Purplehermann says:

      Are you joking? (I’m really not sure)

  6. onyomi says:

    This seems to assume a utilitarian ethics not all readers may share, but I guess the collaborators did? Even so, the utilitarian calculus is incomplete as it fails to take into account the psychological harm and other possible knock-on effects of performing unnecessary surgery on infants too young to consent. Also doesn’t consider any utilitarian arguments in favor other than health, such as e.g. costly cultural identity symbol.

    Since it seems the exception in having arrived at a fairly clear answer, I’d also be interested to hear more about how the person who started out against the proposition updated. Was it simply a matter of learning the health benefits were greater and the risks lower than you previously thought?

    • blacktrance says:

      the utilitarian calculus is incomplete as it fails to take into account the psychological harm

      Or the physical harm. Would you cut off some minor part of your body for these kinds of minor health benefits? I know I wouldn’t.

      • Scott Alexander says:

        If I could have my bellybutton disappear in order to get these physical benefits, I think I would say yes (I probably wouldn’t go in for surgery because it sounds expensive and I’m busy, but that doesn’t seem to be an issue here). Do you think that’s a fair analogy?

        • sclmlw says:

          It feels too far below the threshold where I should care about it. Have we really come to the point where we fret about this kind of fraction of a percent incidence disease, reducing it to an even smaller fraction of a percent? At what point do we say it’s too infrequent to worry about?

          • acymetric says:

            Is this meant to be an argument for or against circumcision? It sounds like an argument for “who the heck cares, it barely matter either way” but I’m not sure that was the intent.

          • zluria says:

            If you add together the incidences of AIDS, phimosis, and UTIs, you get about 5 – 10%. That’s the most surprising conclusion of this essay: The science is clear, and the health benefits are substantial. It isn’t about fractions of a percent.

          • onyomi says:

            Part of the problem with weighing the health pros and cons is that they strike me as clearly born of motivated reasoning. That is, we had circumcision, first as a Jewish identity thing, then as a weird anti-masturbation thing by weird people who thought breakfast cereal was the answer to all health ills, and then we figure out “hey, seems it has some benefits, too!” Problem is we wouldn’t come up with this idea de novo just based on the incidence of e.g. phimosis. Rather, we’d do like we do with other diseased body parts and exhaust all other options before cutting them off.

            If you had a society where all women, due to tradition, cut off one breast, you might find that there are actually some benefits to having one less breast, such as lower incidence of breast cancer and back pain. But in the absence of a pre-existing tradition it would hardly meet the presumption I think should exist against removing non-diseased body parts from nonconsenting infants on the odd chance they could become diseased.

          • tomatipea says:

            Pretty much what onyomi said. If we’re not okay with a teenage girls parents ordering her to get a mastectomy to reduce cancer risk just of petty body autonomy reasons it’s unclear why we’re fine with infant circumcision.

          • aristides says:

            @onyomi
            The counter possibility is that good practices culturally evolve faster than genetic evolution and outcompete those that do not. If circumcision was never invented and these health benefits were real, it’s likely that humans would have eventually evolved to not have for skin. Instead, a small cultural tribe discovered it, the practice spread to other cultures due to a weird combination of religion and health, and is now the dominant practice in many areas. A lot of other cultural ideas evolved this way, isn’t it possible that circumcision is one of them?

          • Thegnskald says:

            Additionally, I think the adult complication rate is probably more accurate than the childhood complication rate, owing to the fact that adults are both cognizant of changes, and can vocalize them.

            Which is to say, I’d guess the rate of infant complications is more like 6%, if we were to judge complications for infants on a similar basis as adults.

            Additionally, I’m not sure about the age range for the complications, in particular the cutoff right before puberty.

          • onyomi says:

            @aristides

            good practices culturally evolve faster than genetic evolution and outcompete those that do not

            Is there evidence of circumcision catching on anywhere in the world for health reasons? My impression is the direction is going the other way: people who have done it traditionally for cultural and religious reasons continue to do so and continue to research whether it might somehow be beneficial, but places where there’s no religious or cultural history are not interested.

            I expect its incidence will fall off dramatically within the next few generations in the US. That will not, by itself, mean that circumcision was wrong; after all, not vaccinating has gotten and might continue to get more common. However, if people are so worried now about health risks to non-consenting infants that a few of them will turn down some quick injections to protect against deadly diseases, I think a lot more people are going to start turning down an elective surgery to protect against much rarer, largely less serious problems.

        • blacktrance says:

          I’m not sure what kind of physical procedures you’d have to undergo to have your bellybutton disappear. If you’re imagining it disappearing magically without a trace, it’s not analogous.

          Better to compare it to, say, cutting off your ear lobes. They’re not useful, but I definitely wouldn’t want to go through that physical pain for these benefits.

          • Lots of people—most women in my society—punch holes in their ears for pretty minor reasons, some of them punch holes in other parts of themselves. That looks like evidence that very minor bodily mutilation is not seen by most people as a serious problem.

          • blacktrance says:

            While ear piercings (and piercings in general) aren’t so bad that no one would ever do them voluntarily, I do think they’re bad enough that it’s wrong to perform them on nonconsenting children (which does happen).

            And people doing it voluntarily seems like one of those culturally contingent things that would look crazy to an outsider.

          • @Blacktrance:

            It seems a bit crazy to me too. I was responding to your comment:

            Would you cut off some minor part of your body for these kinds of minor health benefits? I know I wouldn’t.

            by offering evidence that lots of people are willing to engage in minor surgery for minor benefits.

          • blacktrance says:

            Yeah, but there are many things that lots of people do voluntarily that would nevertheless be bad to force on non-consenters. And cultural views of the practice are relevant to a utilitarian analysis because it matters whether people do it because they see the benefits as outweighing the costs or simply because it’s normal.

            If circumcision weren’t the norm, I think many people would judge these benefits to not be worth the costs – uncircumcised men wouldn’t flood the hospitals motivated by a desire to reduce their UTI and cancer risks. So even if I didn’t care about autonomy in itself I’d still discourage infant circumcision out of concern for their well-being.

          • EchoChaos says:

            @blacktrance

            But circumcision isn’t being forced on anyone. It is only performed by the consent of the person legally responsible for consent.

          • blacktrance says:

            If someone else has legal ability to consent in your stead and you can’t refuse, there are massive opportunities for things to be forced upon you. For example, if a girl’s mother consents to have her daughter’s ears pierced while the girl cries and protests, that’s clearly a consent violation. Of course, newborns can’t indicate consent and older children are limited in their ability to evaluate and appreciate the consequences of their actions, but that’s why parenthood is morally difficult and requires great care for both the child’s autonomy and well-being – it’s not a blanket license to consent in their stead.

          • devonian22 says:

            @EchoChaos It’s being forced on infants without their consent – which might be appropriate if medically necessary (e.g. vaccination), but strictly this is elective surgery.

          • EchoChaos says:

            @devonian22

            Infants cannot consent, so their parents consent for them for everything, elective or not.

            Given that this is an elective procedure with minor positive effects that cannot be put off to have the same effects (believe me, much tougher when you do it at 20), that seems like exactly the sort of thing that we rely on parents to consent to.

          • dionisos says:

            Infants cannot consent,

            This is why you avoid doing choices for them which imply permanent change, and instead do choices which let them with more options later.

            Not a strong principle, but a good heuristics, and one I think very appropriate here.

        • TheTrueScotsman says:

          No I don’t think this is a fair analogy because your bellybutton does not carry any psychosexual significance. I think a better analogy would be a labiaplasty. If it were shown that labiaplasties slightly reduced the risk of UTIs (10x more common in women) would infant labiaplasties be acceptable?

      • J Mann says:

        I don’t know. Could my parents and doctors have tried harder to save my tonsils and wisdom teeth? I honestly have no idea, and I was certainly older, but I don’t remember really being consulted.

        • Nick says:

          I was curious about this and started looking, too; tonsillectomies seem to have gotten less common. Wisdom teeth removal still seems to be quite common, but when I started looking for numbers, I was seeing similar “maybe you don’t need your wisdom teeth removed” articles. Still, these two seem to me to be evidence people will consider such procedures for minor health benefits.

          ETA: I should mention the reason I didn’t link numbers is because I had a terrible time finding any; the numbers quoted to me were actually in a few articles my coworkers found. If someone more curious than me finds a good source, do link.

        • Jaskologist says:

          Wisdom teeth do seem like a good comparison. We remove those as a purely preventative measure, even if they’re not currently causing problems.

          Tonsils aren’t chopped preemptively, but there’s not much hesitation if they cause problems.

          In all three of these cases, the procedure is minimally invasive with little risk of complication.

          • hls2003 says:

            Wisdom teeth removal recovery is pretty rough though. My wife had it done and she was hurting badly for a week and sensitive for weeks after.

          • aristides says:

            @hls2003
            Yeah honestly, I think I’d rather have forskin cut off, than my wisdom teeth removed again (disclaimer I was circumcised as an infant). Taking out wisdom teeth does seem to have more health benefits than circumcision, so it’s not a done deal.

          • devonian22 says:

            We remove wisdom teeth as a preventative measure but we should probably stop doing that as it causes a great deal of morbidity for little benefit. Two thirds of such extractions are unnecessary.

          • Thegnskald says:

            As compared to 97% (ish) of circumcisions being unnecessary.

    • Radu Floricica says:

      Psychological harm seems to be mostly induced by society. I’m pretty sure in Israel it’s either a non-issue or a point of pride. I have a more-than-sneaking suspicion many psychological harms are the same.

      In which case the actual decision depends on the point of view. From a parent’s pov, you may disagree but lean towards the wellbeing of your son anyways. From our pov as dispassionate observers, we can put the blame squarely at society’s feet.

      • BlindKungFuMaster says:

        I think psychological harm is mostly induced by a genetic predisposition towards high neuroticism. What then harms you is left to chance and the environment you grow up in, but you are gonna find something.

        • Radu Floricica says:

          True – but it’s the society that defines the triggers (pun intended). And it’s not a large jump to think that a society that provides more triggers and encourages you to find them is going to give more scope to the genetic predisposition.

          • BlindKungFuMaster says:

            I agree.

            I thought you were coming from the opposite direction: Society harming because it doesn’t pay attention to potential harm, instead of society harming by paying a lot of attention to potential harm.

      • edanm says:

        > I’m pretty sure in Israel it’s either a non-issue or a point of pride.

        Israel is not homogeneous. There are certainly people here who worry about this and fret over whether to circumcise their children or not (and some choose not to). I think the majority of people don’t particularly care and just consider it part of Jewish identity.

        I can’t say that I know many people who have been psychologically harmed, but I wonder if it would ever come up. Personally I find it to be mostly a non-issue for myself – probably because it’s not like I can compare with being non-circumcised.

        • Aapje says:

          I can’t say that I know many people who have been psychologically harmed

          How would you know? Studies have found that pain in babies can cause a large stress response, even so severe that it kills them. With many mohels not using any sedation or only using minimal sedation, there may be substantial stress with substantial after-effects.

          The stereotype of Jews is that they have high anxiety. Anxiety also seems like a common reaction to trauma. 1+1=2?

          • flame7926 says:

            Or anxiety as a reaction to cultural trauma – an identity linked for centuries with a history of persecution seems much more plausible a mechanism to me – even saying the stereotype is anything but another moderately anti-semitic stereotype

          • Aapje says:

            Stereotypes are often (partially) correct, so saying that something is a stereotype is not a good way to dismiss it.

            I briefly looked and found a study that compared anxiety between ethnic groups, although unfortunately not Jews. It found that GAD, SAD and PD is about twice as common in white Americans than in Asian-Americans. So why could it not be true that it is more common for Jews?

            Note that the stereotype that anxiety is a Jewish stereotype may be the cause for a lack of studies.

          • Don_Flamingo says:

            I figured that all the optimistic jews didn’t survive WW2.
            (not literally of course, but it would seem frivolous not to assume a strong selection effect)
            Isn’t it mainly an Ashkenazi stereotype? Did that stereotype even exist before WW2?

          • edanm says:

            > How would you know?

            I don’t, that’s why I said I’m not sure if it would come up.

            > With many mohels not using any sedation or only using minimal sedation, there may be substantial stress with substantial after-effects.

            > The stereotype of Jews is that they have high anxiety. Anxiety also seems like a common reaction to trauma. 1+1=2?

            I mean, as the father of a child, I can tell you that whether it is “traumatic” or not, babies go through lots of trauma basically all the time. I don’t have any evidence to back this up, but the idea that this is specifically so much more traumatic that it causes people to be more anxious seems a bit laughable.

          • darkwingduck says:

            That stereotype also includes Jewish women (the constantly fretting Jewish mother archetype, for example). I really don’t think circumcision in infancy causes higher rates of anxiety.

          • Don P. says:

            Remember that any such line of thought has to apply to Muslims as well.

          • Jacobethan says:

            Pure anecdote, but what I’ve heard from pediatricians is universally, “Go to a mohel if that’s an option for you — they’re much better at it than we are.”

            As to the larger point (as others have said, and as I noted in response to a comment further down). Whatever your theoretical model for infant reactions to trauma, it utterly strains belief that any observer of infant behavior would single out THIS particular stimulus as likely to be traumatogenic.

  7. Vergence says:

    Interesting write-up, thanks. I am now wondering to what extent the health benefits can be gained in other ways (e.g., proper cleaning).

  8. RLM says:

    What were the opinions of the authors going in to this? This doesn’t seem, to me, to be the type of thing that people who disagreed on the ethics of circumcision would write.

    The title of this AC is “IS INFANT CIRCUMCISION ETHICAL?” So, I expected the entire AC to focus on ethics. Instead, it seems to cover minor health concerns for about 80%, then has an anemic ethics section that essentially just says “it depends on your ethics system.” The ENTIRE POINT of this paper is to talk about the ethics!

    Is the ethics discussion here so weak because the authors couldn’t agree on anything?

    • Evan Þ says:

      Or, did both authors profess consequentialism in which case the health concerns are very relevant, and add on an anemic afterward acknowledging that other ethical systems might see the matter differently? That’s how I read it.

    • blacktrance says:

      Most ethical views ascribe at least some importance to consequences, so the medical effects are highly relevant.

    • Wency says:

      The question was framed wrong, but they basically tackled the right question. “Do the benefits of circumcision exceed the risks?”

      I’m glad they didn’t spend much time on ethics per se, and I only glanced at that last paragraph labeled “ethics”, while studying their numbers with close scrutiny. If they had focused on ethics, this paper would just be philosophical noise, representing perhaps two points of view on the nature of ethics, with many readers likely disagreeing with both of them. Instead we got some actual research and a summary of data.

  9. chaosmage says:

    This seems good, but I’m baffled at the absence of any mention of religion. In my country, circumcision is very unusual and would likely be interpreted as a religious signal above all else.

    • zluria says:

      But outside of religous Jews, what relevance do religious arguments have to the question of whether circumcision is ethical?

      • acymetric says:

        At least in the US, a lot of Christians also consider it a religious deal (something, something, “fullfill the law, not abolish it” mumble, (pay no attention to the other “laws” we blatantly and explicitly ignore) mumble.

        • Evan Þ says:

          We do? What I’ve always heard (in Baptist circles) is “it doesn’t matter; it’s fine to do it or not, whatever you want.”

        • Nick says:

          I’ve never heard a Christian case for circumcision, either. Is there a particular source you got this from? Conversation, a pastor, an article?

          • EchoChaos says:

            Some Christians (like me) still follow the Old Testament laws, so we believe we are commanded to circumcise our sons on the eighth day.

          • RC-cola-and-a-moon-pie says:

            Echo, I’d be very curious how those with your views deal with the Pauline teaching on circumcision. Whatever one thinks of the continuing application of other parts of the OT system, it strikes me as extremely difficult to view circumcision as required for Christians assuming you take the usual view of the canon of scripture.

          • Randy M says:

            I thought that debate was over a rather long time ago?
            edit: What he said.

          • EchoChaos says:

            @RC-cola-and-a-moon-pie

            Oh yeah, Paul’s teachings. You mean when Paul had Timothy circumcised before he could begin his ministry, right? 😉

            I tease because it’s a major point of debate amongst a lot of us, to be fair. Most people believe that what Paul was teaching with Titus was that it was voluntary and not compulsory based on Galatians 2:3

          • Nick says:

            Yeah, this is definitely the first time I’ve ever heard this. Thanks for sharing.

          • RC-cola-and-a-moon-pie says:

            Thanks for the response. I don’t want to sidetrack into a discussion of theology (even though it is tangentially relevant) but man, I would love to see some exegesis of, say, the Galatians discussion from the perspective of someone claiming that Paul taught that circumcision was binding on Christians! (Like the part where he wished the circumcision advocates would go the rest of the way and just castrate themselves, for instance.) At the end of the day though I come down where you are on the policy question of whether it is ethical. Even if this collaboration leans a bit toward the pro-circumcision side I think that’s a helpful corrective, because (like Scott’s experience) many of the discussions of the topic of circumcision I’ve seen have been extremely unbalanced the other way, and presented with a great deal of confidence and emotion. Seems worthwhile to lay out the fuller picture.

          • EchoChaos says:

            @RC-cola-and-a-moon-pie

            Yeah, Paul’s ministry was dogged by Judaizers, who were telling Gentiles that they had to follow the law to be saved, which is untrue and caused some harsh rhetoric towards them.

            The question is entirely different from whether following the Law is good in and of itself, which Paul clearly thinks it is, because he continues to follow it to the end of his life, including performing (or attempting to perform in one case, as he was arrested on the way) ritual sacrifices.

            The fact that he has Timothy circumcised shows that it is indeed something he regards as valuable.

            This is the same as my belief. I don’t believe that being circumcised or not eating pork saves me, but I do believe that when the Creator of the Universe puts down a rule, it’s one that will make my life better to follow, even if I don’t fully understand His reasoning.

          • Wency says:

            EchoChaos, I’d be curious if this is a matter of your church or simply a matter of conscience you reached independently, without others at your church doing the same.

            My understanding is Seventh Day Adventists adhere to much of the Law, including keeping kosher, but still no requirement to circumcise.

            I don’t think it should be unexpected that some Christians would seek to uphold the ritual requirements of the Law, as it’s a thought many of us have after reading the Pentateuch. But like Evan and Nick, I’ve never met such a person in the flesh.

          • EchoChaos says:

            @Wency

            My church, but Messianic churches in general follow the same.

            I probably shouldn’t have used “commanded” because it sounds a bit too strict and can imply I believe it has a bearing on salvation, which it absolutely doesn’t. But it’s generally a good word to use regarding the Law, which is of course just and holy (Romans 7:12).

            I am, as I’ve previously mentioned elsewhere, a deacon, so I have to be familiar with the doctrine and arguments, although admittedly not always perfectly.

          • Nick says:

            @EchoChaos
            It seems to me you’re still confusing whether it’s obligatory or not. I don’t think God—or anyone else for that matter—lays down optional “commands.”

          • zoozoc says:

            @Nick

            I would say that Jesus and the New Testament teachings make clear that things are no longer as simple as “this is commanded and must always be done”. Rather, for many things there is leeway and room for matters of conscience. We now have the “law” written on our hearts by the Holy Spirit, and the Spirit can lead people to different conclusions on different things. I think Romans 14 is the clearest area of scripture about “matters of conscience” and how they should be handled.

            Now I want to be clear that the Bible definitely makes clear that some things are always wrong and always sin.

          • Some Christians (like me) still follow the Old Testament laws

            Interesting. Is that limited to laws explicitly stated in the Old Testament, or do you accept the expansion of those laws under Rabbinic interpretation?

            For example, do you avoid mixing meat and milk, or only avoid boiling a kid in its mother’s milk?
            (from someone else)

            I don’t think God—or anyone else for that matter—lays down optional “commands.”

            Echo’s description of his position sounds to me like the equivalent of the Islamic attitude to acts that are sunnah, but not required. Mohammed did his prayers in some particular way (or did something else in some particular way). He never said that doing it that way was required. So a Muslim doesn’t have to do it that way, but since Mohammed was the best of men and divinely inspired, copying what he did is probably a good idea.

          • EchoChaos says:

            @Nick

            It is obligatory, but if you fail to perform it, you can be forgiven, just as with any other sin.

            https://biblehub.com/kjv/romans/6-1.htm

            @DavidFriedman

            I read the rabbis, because they have a lot of wisdom and experience in judging the matters, but I do not regard any halacha as binding. For that particular example, I do eat milk and meat together.

            I regard the commandments as more serious than just “it’s a good idea”, although they are also that. Just as a believing Christian knows he CAN engage in sexual immorality and be forgiven, but does not. See my early Romans quote.

          • Space Ghost says:

            @EchoChaos so do you keep kosher? How do you reconcile that with Jesus’s teachings that food cannot defile (Mark 7:1-23)? If you do keep kosher, why do you do it?

          • EchoChaos says:

            @Space Ghost

            so do you keep kosher?

            Yes.

            How do you reconcile that with Jesus’s teachings that food cannot defile (Mark 7:1-23)?

            The context there is rabbinic restrictions on eating clean food, not whether or not the food itself is clean. Specifically that their hands are defiled (Mark 7:2) and that is not allowed under the rabbinic interpretation. The fact that he emphasizes “You have let go of the commands of God and are holding on to human traditions” tells you it isn’t about the clear commands of God (don’t eat pork/shellfish) and about some rabbinic rule.

            If you do keep kosher, why do you do it?

            Because God told me to do so.

            As Jesus himself said, no part of the Law shall depart until heaven and earth pass away, which still hasn’t happened.

          • RC-cola-and-a-moon-pie says:

            Echo, and Acts 10? And the Jerusalem council at Acts 15? With enough ingenuity one can find a way to rationalize nearly anything (although reconciling the Pauline materials with an obligation to circumcise may win someone a world record in competitive eisegesis). But taking the scriptural sources as a whole and without building a reading around preordained conclusions it strikes me as really tough to maintain an obligation to keep the whole of the OT law. The centerpiece of the OT law was the sacrificial system—do you sacrifice animals? The beauty of the new covenant is that it rationalizes the destruction of the Temple and the forced end of sacrifices because the system was completed by the final sacrifice to which the others pointed, right? These things don’t just carry over! Anyway, I say all this with respect. I admire your sincerity and commitment—I know that getting an adult circumcision is no casual matter.

          • Space Ghost says:

            @EchoChaos ok, but it doesn’t just address handwashing. I don’t consider myself a Biblical scholar or anything, but in Mark 7:1-23 of KJV, Jesus says

            “There is nothing from without a man, that entering into him can defile him: but the things which come out of him, those are they that defile the man.”

            and

            “Are ye so without understanding also? Do ye not perceive, that whatsoever thing from without entereth into the man, it cannot defile him;

            Because it entereth not into his heart, but into the belly, and goeth out into the draught, purging all meats?”

            I don’t see how you can reconcile that with Leviticus 11 (which is entirely about unclean animals) in the way you have. Is your claim that the commandments in Leviticus are essentially arbitrary? “Do not do this, because I say so” and not “Do not do this, because it is unclean”? Why the extensive justification if it’s ultimately an arbitrary command?

          • EchoChaos says:

            @RC-cola-and-a-moon-pie

            Acts 10 is easy, since Peter gets the interpretation of that vision in the chapter.

            Acts 10:28 “He said to them: “You are well aware that it is against our law for a Jew to associate with or visit a Gentile. But God has shown me that I should not call anyone impure or unclean.”

            Note that he is again referring to a rabbinic law (nowhere in the Torah is that written) and he says that the vision showed that he should not call anyone impure, not any food. So the vision was about people, not food.

            Acts 15 DOES put dietary restrictions on people, so I am not sure how it is an argument against dietary restrictions.

            I believe that’s a minimum set of “here is the basic code of behavior for a believer”, since it’s clear that none of those acts can save and that following the rest remains good.

            The centerpiece of the OT law was the sacrificial system—do you sacrifice animals?

            No. Sacrificing outside the Temple is strictly forbidden, so I don’t do it. I would sacrifice at the Temple if it existed (and the Jews allowed a Christian to do so).

            The beauty of the new covenant is that it rationalizes the destruction of the Temple and the forced end of sacrifices because the system was completed by the final sacrifice to which the others pointed, right?

            Paul himself continued to sacrifice after being saved and was arrested on his way to sacrifice. So obviously not all sacrifices are done away with.

            There are actually sacrifices for multiple things. Some are for transgression, but some are for praise and thanksgiving and some are for remembrance.

            Just because a perfect sacrifice has been made for transgression does not mean that sacrifices of praise and remembrance are no longer made.

          • EchoChaos says:

            @Space Ghost

            And I totally agree with Jesus on that (obviously). What defiles someone who eats an unclean thing is the disobedience coming from within, not the food itself.

            But given that God does not change (I think we can agree with that), if food was unclean in Leviticus, it is unclean today.

            And in a session in which He specifically upbraids people for following men’s rules instead of God’s Law, I can’t justify to myself that in the same moment He is also telling people to follow different rules than God’s Law.

        • hls2003 says:

          Agreed with Evan and Nick – I have never heard a Christian argument that circumcision is religiously mandatory. Always presented as optional to me. I see EchoChaos takes a different view below, but he is literally the only Christian I have interacted with personally (and talked about this issue with, I guess I should qualify) who has stated that position. So consider me updated that they exist, I suppose, but I still think that’s a significant outlier position amongst Christians.

        • JohnBuridan says:

          In my experience, I have only ever heard an anti-Jewish case by Christians against circumcision. I also feel like you are forgetting Paul to the Galatians on circumcision:

          “Mark my words! I, Paul, tell you that if you let yourselves be circumcised, Christ will be of no value to you at all. Again I declare to every man who lets himself be circumcised that he is obligated to obey the whole law. You who are trying to be justified by the law have been alienated from Christ; you have fallen away from grace. For in Christ Jesus neither circumcision nor uncircumcision has any value. The only thing that counts is faith expressing itself through love.”

          But maybe you know some Christians personally who have said what you say the say?

          • EchoChaos says:

            Why then did Paul have Timothy circumcised?

          • Evan Þ says:

            @EchoChaos, the way I interpret it, in line with my pastor and the commentaries I’ve read, is that Paul was doing it to avoid needless criticism from Judaizers that would distract from his message. “To those under the law I became as one under the law (though not being myself under the law) that I might win those under the law” (1 Corinthians 9:20).

            By your interpretation, why then did Paul not have Titus circumcised?

          • Jaskologist says:

            For the same reason he might advise some people to abstain from wine or meat; as a concession for the “weaker brothers“.

          • JohnBuridan says:

            Because Timothy was Jewish and had a Jewish Mother, presumably.
            Just taking the first DuckDuckGo result of “Timothy Circumcised”, I got this fairly reasonable interpretation. Agree or disagree as you like.

            https://www.desiringgod.org/articles/why-was-timothy-circumcised

            Your point is made though. I see that the Messianic Millenarian type of Christians see respect for Jewish customs as somewhat essential. So would you say that maybe ~1% of US Christians believe in getting circumcised for religious reasons?

          • EchoChaos says:

            @Evan Þ

            is that Paul was doing it to avoid needless criticism from Judaizers that would distract from his message.

            Avoiding criticism from a group that you dislike so much you advocate them emasculating themselves doesn’t sound very Paul, especially as he is very willing to criticize others in that way.

            By your interpretation, why then did Paul not have Titus circumcised?

            Because he chose not to, I assume.

            @JohnBuridan

            So would you say that maybe ~1% of US Christians believe in getting circumcised for religious reasons?

            That seems accurate to me.

      • eric23 says:

        And Muslims, of course.

      • Aapje says:

        @zluria

        If you care about your society being hospitable to Jews/Muslims, religious arguments also matter to you by transference, even if they aren’t directly persuasive.

        • zluria says:

          I see what you mean. If it turned out that the risks of circumcision outweighed the benefits, it might still make sense to allow the operation in order to be hospitable to Jews and Muslims.

          However, this is strictly a hypothetical situation, as it seems clear from the above that in fact circumcision has substantial benefits, so much so that it might make sense to mandate circumcision of infants, as we do with vaccination.

  10. Peter Shenkin says:

    I have a question and a comment. Here’s the question. (I’ll make the comment in another response.)

    “For men who exclusively have sex with men and for men who do not have sex, the benefits and risks are close to equipose.” — i.e., circumcision has greater health benefit for men who have sex with women.

    I didn’t see the basis for this in the information you presented; perhaps I just missed it somewhere in there. Could you elaborate?

    • hnau says:

      STDs section, middle of second paragraph. But they way they presented it there makes me think it’s absence-of-evidence rather than evidence-of-no-effect, so I disagree with the conclusion’s framing.

    • Aapje says:

      Here is a meta-study. 29 out of 45 studies that looked at HIV transmission among men who have sex with men, didn’t find a scientifically significant protective effect, while the others did.

      This meta-study still concludes that circumcision has a protective effect, but depending on how likely you believe it to be that scientists (in general) consciously or unconsciously manipulate the outcomes to get a positive result, you can either believe the average reduction or be more swayed by the vast majority of studies not finding a significant effect.

      Note that an interesting finding of that paper was that the protective effect seems larger in low/medium income countries, where (probably due to more traditional gender norms) men who have sex with men are more likely to also have sex with women (40–70% in China, India, Peru, and sub-Saharan Africa). So the protective effect that was found can actually be a protective effect during hetero sex, which is falsely attributed to homo sex, because these studies often don’t seem to actually try to distinguish between men who only have sex with men and bisexual behaviors.

  11. Aponymouse says:

    Anecdotal evidence re: penile sensitivity here: a friend on mine had glans hypersensitivity as an adult, to the point of being unable to touch exposed glans unless extremely aroused and also having considerable problems receiving oral sex. After researching the topic his conclusion was that while infant circumcision does not seem to significantly reduce hypersensitivity (and premature ejaculation) rates, adult circumcision does. Not willing to go through surgery and also willing to retain some of the benefits of having a foreskin, he instead learned a foreskin folding technique that was effectively equivalent to circumcision in terms of glans exposure. After applying that technique consistently for several months (basically simulating circumcision) he reported greatly reduced glans sensitivity, much simpler hygiene and considerably improved sex life as a result of that. He also cited some Middle-Eastern study (I want to say from Iran?) treating premature ejaculation in partially circumcised men (i.e. where the glans was not completely exposed after the initial procedure performed on infants) that showed great results after completing the foreskin removal and fully exposing the glans, but I’m having trouble sourcing it right now.

  12. 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.

    Why? What are those reasons?

    Also, you seem to assume that decrease in sexual sensitivity is an unambiguous minus, but that isn’t clear. One limit to the length of intercourse is how long the man can go before he has an orgasm. Reduced sensitivity may reduce the intensity of the pleasure but increase its duration.

    • Peter Shenkin says:

      I see that my comment below relates to an issue you raised.

    • Evan Þ says:

      I’ve been told that might also significantly increase the pleasure of that man’s female partner.

      • devonian22 says:

        Anecdotally, circumcision reduces the pleasure of a female partner – the glans is drier more keratinized, and there’s no foreskin to slide back and forth.

    • Solra Bizna says:

      Also, you seem to assume that decrease in sexual sensitivity is an unambiguous minus, but that isn’t clear. One limit to the length of intercourse is how long the man can go before he has an orgasm. Reduced sensitivity may reduce the intensity of the pleasure but increase its duration.

      My infant circumcision was slightly botched. Aside from the “normal” complications of circumcision, I have a nasty knot of scar tissue there now. My sensitivity is low to the point that I’m almost incapable of ejaculation through intromission. The fact that it takes me hours every single time was enjoyable for my partner at first, but it quickly became frustrating when she realized I was experiencing literally no pleasure through most of the act.

      Bonus prize: intermittent but very distracting chronic scar pain. Imagine if Harry Potter’s scar were on the most sensitive part of his “wand” instead of on his forehead.

      Slightly unrelated, I have repeatedly heard claims from men who were circumcised as adults that there was no sensitivity change across the operation. This does seem to refute the claim that the frenulum itself is important to sexual pleasure, but I am not convinced on the topic of glans keratinization. Doesn’t it make sense that adult men would be better at avoiding chronic glans irritation than helpless infant children are?

      • Thegnskald says:

        Of the men I’ve dated who were circumcised, I’m 100% for “Some problems arising from circumcision”, ranging from total lack of sensitivity, to skin migration from the testicles, to scarring, to painful erections from insufficient skin.

  13. Peter Shenkin says:

    Aside from (1) health, where I think the answer is clear, and (2) ethics, where there’s less clarity (especially if you divorce if from the health benefit), there is also the question of sexual performance and pleasure, which you mention, and, umm, cite possible citogenesis. I have an anecdote to relate.

    A friend of mine is uncircumcised. He once mentioned to me that he wishes he had been circumcised. I, being Jewish, and therefore having been circumcised, was surprised at this. I asked why he felt that way. His response was his belief that “circumcised men can keep it up longer”. I said that I, on the other hand, had the impression that “uncircumcised men have more fun.” This may be an example of double citogenesis, or maybe double grass-is-greenerism.

    So, in an attempt to enlist an unbiased arbiter, I asked a female friend of mine who was very experienced and had had lots of sexual partners (all male, as far as I know) what she thought. She immediately said “You’re both right!” She didn’t have to think about that one at all. So I asked, “Well, other things being equal” (with a full understanding that they never are), “which do you prefer?” She kept going back and forth, basically saying, “well this, but on the other hand that…”, and in the end she could not really decide. But she still stood behind her impression that my friend and I were “both right.”

    • aristides says:

      Anecdote, two of my female friends greatly prefer Circumcised penises, but those were for the reasons stated in the article: they enjoy giving oral sex to circumcised penises, but did not enjoy it with uncircumcised penises. Cleanliness was only one factor, they both just felt circumcised penises looked uglier.

    • CompartmentalizedIdentity says:

      Anecdotally, as a person who has sex with men, I found that circumcised men have difficulty orgasming / take much longer to orgasm, and that in general terms I like having sex with men who are circumcised because I wanted to have sex with them anyways, not because of any sexual superiority/inferiority.
      Being able to directly touch another person’s sexual organs without lubricants or any special setup and confidently know you aren’t hurting them handling them too roughly makes a lot of sexual interactions flow better, feel more playful/fun, and more intimate.
      Describing any man as anything but paragon sexual potency and enjoyment is a very strong taboo in western culture, so I wouldn’t be surprised by women reacting with ambivalent or answers or non-answers to inquiring men.

      • Peter Shenkin says:

        @ CompartmentalizedIdentity

        FWIW, I don’t think the woman I was talking to was exactly being ambivalent, at least for the reason you mentioned, when I asked her preference. I think she liked both for different reasons and couldn’t really say that she liked one better than the other.

  14. Brett says:

    One caveat I’d put on the HIV studies is that the 50% figure is the relative risk reduction from circumcision. The absolute risk reduction is pretty low.

    • Garrett says:

      From what I’ve read in the past, this is a reduction on a per-incidence basis. So if you end up hooking up once with someone who’s HIV positive, you end up halving your risk of contracting HIV. But if you are involved in a long-term relationship (assuming no condom use) with someone who’s HIV-positive, the law of large numbers says that you’re going to get infected either way.

  15. zluria says:

    People seem to be surprised that the conclusion for circumcision is so clear-cut, especially since it is associated with backward cultish religions. So was I:

    When our son was born, this was a major dillema! I read up on it quite a bit, and talked to several circumcised and uncircumcised people.
    Initially, I was leaning against circumcision, because:

    (1) I thought the health risks and benefits kind of cancel out.
    (2) I thought that sexual enjoyment could be impaired.
    (3) I didn’t want to cause my baby needless pain.

    The issue of autonomy makes no sense to me in a society where we vaccinate our children and make medical decisions for them until age 18 or so.

    Reading up on the issue convinced me that
    (a) The health benefits are actually substantial.
    (b) Our best evidence suggests that sexual enjoyment is not impaired.

    Additionally, after the baby was born I realized that he experiences terrible pain all the time in any case – he was terrified of having a bath, had awful stomache pains, etc. The circumcision itself turned out to be only the third worst thing to happen to him that day.

    • eccdogg says:

      I have two daughters so I was never forced to actually make this decision, but prior to finding out their sex my wife and I had a discussion on this. She deferred to me as she felt she did not have the necessary perspective.

      Ultimately I decided that if we had a boy he would be circumcised and it had very little to do with medical arguments. It was almost entirely cultural so long as I could not find strong medical arguments either way. I simply wanted my son to look like his dad and I was happy that my own parents had me circumcised. Had I lived in a culture other that the USA I certainly would have chosen differently.

    • The circumcision itself turned out to be only the third worst thing to happen to him that day.

      Best line in this discussion so far.

      • devonian22 says:

        So it’s okay to hurt people who are in pain because they’re already in pain?

        • So it’s not okay to posit large traumatic effects from a particular source of pain when there are lots of other and larger sources of pain.

          • devonian22 says:

            Per Lander 1997, a comparison of different techniques for pain relief during circumcision, circumcision without anesthesia actually causes a great deal of pain – so much so that the authors had to stop enrolling infants in the placebo group because it would have been unethical to do so.

          • Jacobethan says:

            The authors in that study are comparing with-anesthesia vs. without. Unsurprisingly, they find there is more distress without; the less predictable finding is that the pain mitigation from anesthetic dominates any added distress associated with having it administered. This is a useful finding — if you don’t have compelling religious reasons for withholding anesthesia, you should definitely use it.

            In that context, it makes sense to characterize the un-anesthetized group as experiencing “great distress” or “extreme distress” relative to the treatment group(s) that had shorter, less intense bouts of crying (and associated physiological markers).

            What’s not clear to me is that the former level of distress is particularly unusual at an age where episodes of distress that might reasonably be called extreme happen routinely, even several times a day. Maybe the elevated heart rate and duration of crying the authors report is way beyond what happens in a typical infant tantrum — I’m certainly not an expert here — but they don’t say so, and (as I guess is obvious) I’m prima facie doubtful.

  16. markk116 says:

    I think the content it pretty good, but the structure and style is kind of jarring to me. I’d like a preface with some context and a nice little introduction. And at the end a conclusions section, where you both wrap up your opinions and how (if) they changed over the course of the writing. It just seems kind of mechanical and stilted.

    • kipling_sapling says:

      Agreed. I mentioned the same thing about conclusions above, but I didn’t mention how jarred I was about the lack of any kind of intro.

  17. maintain says:

    Was anybody anti circumcision before reading this, and still anti circumcision afterwards?

    I am. Am I biased here? I feel like whoever did the anti circumcision side should have tried a little harder.

    Also the ethical part should have been given much more discussion. Is it not completely normal that I want to make my own choices about my own body? (Also, there could have been a discussion of how Muslims and Jews would experience great suffering if they were told they were not allowed to circumcise their children.)

    Some points:

    – There was no discussion on lives saved with circumcision vs lives lost. For instance, they could have compared deaths due to circumcision complications vs deaths saved from penile cancer.

    – There was no discussion on possible bias in the scientific studies. I’m going to assume these studies were conducted by people who were circumcised, and who were themselves pro-circumcision? Were they biased in any way? If creationists conducted a study that showed that creationism was true, would you just accept it and cite it in a debate?

    – No discussion on actual numbers on how many people get HIV through heterosexual sex, vs getting HIV through needles or anal sex. I recall hearing that only 7% of HIV cases are transmitted through heterosexual intercourse. If so, then circumcision doesn’t provide a 50% reduction in HIV transmission, it provides 50% of 7% reduction. Is this true? Also you are using condoms, why would being circumcised have any effect on HIV transmission? Why am I having to bring this up in a blog comment? Shouldn’t this be in the original article. Wasn’t there supposed to be an anti circumcision person collaborating?

    – “If circumcision eliminates important nerves, due to brain plasticity infants are likely better able than adults to reassign the portions of the brain processing the foreskin to other areas of the penis.” This sound like the sort of argument someone would only come up with if they were grasping at straws trying to come up with rationalizations. (Of course, I would say that if I was grasping at straws, trying to come up with rationalizations.) It’s a pretty big point. Is it true? I would have liked some discussion on the neuroscience behind this statement.

    – Some discussion of HIV vaccines would have been interesting. If there is an HIV vaccine in the next 20 years, then the whole HIV discussion re infant circumcision is dumb. I recall hearing about an HIV vaccine that scientists didn’t bother to roll out, since the data showed that it was only 30% effective. Is this true? Are you sure those scientists aren’t biased in any way?

    There are a lot of things I would have liked discussed more. If you want to convince me, you need to actually debate my ideas, not just leave me feeling steamrolled.

    My penis was cut without my permission, and I don’t think I have seen any personal benefits from it.

    • Michael Watts says:

      Was anybody anti circumcision before reading this, and still anti circumcision afterwards?

      I am. Am I biased here? I feel like whoever did the anti circumcision side should have tried a little harder.

      If you want to convince me, you need to actually debate my ideas, not just leave me feeling steamrolled.

      I’m with you. But this does provide a path forward for ideologues in the event that “adversarial collaborations” become some kind of societal norm — just label yourself incorrectly and write a puff piece with your partner. ;D

      • Ceinti says:

        I feel like this is basically what happened with this case. Or at least, whoever was pro-circumcision may have been a lot more pro- than the anti-circumcision person was anti-.

        The lack of discussion of impact of the various reductions/increases in things was a huge missing piece. For example, if 1.5% of 100% of the population get complications from neonatal circumcision vs. only 6% of the ~2% of people who eventually need circumcision as a non-infant get complications, then not circumcising results in 8x less complications in the population.

        Then there’s a complete lack of discussion of costs, both in terms of money and time. If medical practitioner training is so important to avoid bad outcomes, then you have to take into the account the extra time and resources spent on training them. Then there’s the actual cost and time spent each time the procedure is performed, medical professional time on the job is scarce and this is competing for time that could be going elsewhere.

        I imagine that taking things like this into account would more than flip the recommendation entirely considering how minor any of the purported benefits are, but at the very least they should have been taken into account rather than just ommitted and coming to a conclusion anyway. I’m honestly pretty disappointed in Scott for allowing this to go up on his blog, it’s just not really good enough considering he might have a real impact on people’s decisions as a trusted source, especially on this matter since parents have that control to affect real people wheras there are plenty of issues where someone’s opinions might not affect the real world in any way.

        • Garrett says:

          I’m honestly pretty disappointed in Scott for allowing this to go up on his blog

          Please don’t take this out on Scott. There’s that whole “perfection is the enemy of the good” problem. He doesn’t have unlimited to to referee/critique/whatever, and relies on a good amount of the adversarial process to shake this out. Scott should be lauded for the work, effort and money that goes into this even if the results aren’t what we might all prefer.

          I also happen to share your criticisms of this piece.

    • maintain says:

      >My penis was cut without my permission, and I don’t think I have seen any personal benefits from it.

      Wait, I retract this statement. I just did some arithmetic. I’m .000266% less likely to die of penile cancer per year.

    • Purplehermann says:

      I think you have some good points about what could have been done better.

      As for the permission: you were also vaccinated, had your schools and neighborhoods chosen for you, etc etc. As a child you could not be consulted as an adult would be, the operation is generally a net positive, and waiting till you were older would have meant forgoing some benefits. As with everything else in a child’s life, your parent made decisions for you.
      If parents are making the best choices they can that’s all we can ask.

      From an ethics point of view, imposing your ethical system on other people who are responsible for another person whose ethical system isn’t even set yet and couldn’t be known, and holding them to task for making a choice which seems to hold water in a consequentialist ethics system (and most ethics systems have some overlap with consequences) seems childish and unfair.

      • devonian22 says:

        > the operation is generally a net positive

        The post claims this, but I don’t think it’s true.

        The NHS stopped paying for neonate circumcision because the monetary cost outweighed the extremely modest benefits. The risk of complications is non-negligible – the largest study I could find stated a 0.1% risk of serious complications (“those with long-term or life-threatening sequelae”). That’s much higher than e.g. the lifetime risk of penile cancer.

    • eh says:

      I’m mildly anti-circumcision (non-American, so it’s not a cultural norm and my predisposition is against it) and I would have liked to see some analysis of publication bias in the literature – without trying to do so, I’ve ended up seeing lectures on the benefits of circumcision twice, and the professors in question seemed to have an axe to grind. I’m also curious about the potential for psychological harm, which wasn’t covered.

      I think the anti side could have been steelmanned better. If there was no data available for a predicted harm, I would have liked to see that made explicit.

    • cuke says:

      My reaction was very close to yours, maintain.

      I’m a mom who made the decision not to have my son circumcised.

      In a setting where we do have excellent access to healthcare and good sanitation, do not face religious requirements, and do place a very high value on autonomy/consent, the potential health benefits seemed not significant enough to conduct preventative and irreversible surgery, even if fairly minor surgery. BlackTrance asks above: “Would you cut off some minor part of your body for these kinds of minor health benefits? I know I wouldn’t.”

      An irreversible intervention is going to have to meet a pretty high benefit/cost threshold for me to want to make that call on behalf of someone else’s body.

      The fact that this decision did hinge for me on values around autonomy/consent while that value seems nonsensical to some in a parenting context underscores why the question in the title would have been worth exploring. I appreciated the review of research on the medical issues, but for me, a deeper look at the ethics would have been more interesting particularly because what makes this issue “adversarial” is the difference in ethical frameworks (values hierarchies) we bring to the discussion.

      Many people I’ve spoken with about this issue over the years have said, as did someone above, “I wanted our son circumcised so he would look like me [or like my husband].” This is a statement about values. It’s one I have trouble wrapping my head around, just as others have trouble grasping why a parent would have issues with “consent” and “autonomy” when parenting requires making so many judgment calls on behalf of their child. There are some really different world views and priorities at play here and it would be fruitful to tease them out.

      • devonian22 says:

        I wanted our son circumcised so he would look like me

        Agreed that this is incredibly hard to sympathize with.

    • devonian22 says:

      I’m in the same boat – anti before, anti after. Doesn’t feel like a significant effort was made by the anti side here. Notably, the NHS in the UK stopped paying for infant circumcisions not for ethical reasons because the benefits don’t outweigh the monetary cost. Several other medical orgs say similar things.

      The cited study claiming that sensitivity isn’t reduced in circumcised men itself claims that based on another study of forty individuals, twenty circumcised and twenty not. This hardly seems conclusive.

      Same study also claims the glans doesn’t become keratinized after circumcision (which seems hard to believe even if you’ve merely glanced at porn); it cites a study that looked at 15 people. Come on guys!

  18. mwacksen says:

    A very nice adversarial collaboration! I remember reading a study/post/something that claimed something like “if you measure female sexual satisfaction via a questionaire, the correlation that is found is that women prefer uncircumcised men to circumcised men in bed (even though they may think that aesthetically, circumcised penises look better)”. It also presented some (to me) plausible sounding mechanism.

  19. Blueberry pie says:

    It would be nice to have the article define/link to Wikipedia for the less common abbreviations/terms (UTI = urinary tract infection, STI = Sexually transmitted infection, phimosis, …) at first use – maybe Scott can still fix this? 🙂

  20. ana53294 says:

    AFAIK, the appendix is pretty useless, and people who had an appendectomy live a fine life. An appendectomy is still a more involved surgery than is infant circumcision, but if it ever became as uninvolved (magical robots) would you do it to reduce the risk of appendicitis? Appendicitis seems to occur (first google result) at a rate of 7% a year. That seems quite higher than the incidence of all the small conditions described in the article.

    And an appendectomy would be something completely unobservable (modern surgery is quite goot at avoiding scarring). So people wouldn’t even have to be traumatised, since they wouldn’t know.

    So why does nobody advocate for preventive appendectomies? Because there isn’t a community that already practices it anyway for religious reasons. This all seems to me like more post facto justifications (it happens anyways, let’s make lemonade) than an actual ex-ante justification.

    And fine, if you do it for religious reasons, go ahead, but don’t pretend you do it for the health. It confuses a whole lot of people who wouldn’t do it if it weren’t for the health reasons.

    • Rachael says:

      Agreed. I was thinking something similar about appendectomies.

    • eric23 says:

      The appendix may be useful in ways that are not readily apparent, but still have a significant benefit later on.

      Also, appendectomy seems to be much more dangerous than circumcision.

      • ana53294 says:

        Yes, I acknowledge that an appendectomy is a riskier surgery. I am just posing the hypothetical where we find a way to make it much less risky (magical robots). Would the people who advocate infant circumcision advocate for a preventive appendectomy then?

        • flame7926 says:

          I would think they would – I think I would at least. Like getting your wisdom teeth out – I would think that if they were able to be removed painlessly and easily from infants a non-negligible fraction of parents would opt for it.

        • aristides says:

          If you give me magic robots and insurance that covers the full cost (which my insurance does for infant circumcision) I will be first in line to get my appendix removed. I’ve had two appendicitis scares, and I would love to never worry about that again. I would definitely ask my OBGYN to remove the appendix of my infant children, and see if it works on tonsils as well. I’m not sure if I’m in a minority, but I don’t think I am.

    • Robert Jones says:

      Because there isn’t a community that already practices it anyway for religious reasons.

      Yes. If there did not exist a community of people practising infant circumcision for religious reasons, we would not be having this conversation.

    • RalMirrorAd says:

      One difference between this and apendectomies / wisdom teeth is the difference in personal control.

      The studies seemed to be looking at health risk factors that can be mitigated through other means (vaccines, hygeine, etc.) that don’t involve mutilation. I doesn’t seem like problems with the appendix or wisdom teeth can be fixed this way.

  21. Rachael says:

    This was shorter than I expected, and felt a bit lacking, especially on the anti side.

    As one example that I can come up with off the top of my head as a totally uninformed person, I didn’t see anything about the protective function of the foreskin against everyday minor abrasions and an exploration of how much this matters. I was also expecting to see additional health-based anti arguments that were new to me.

    Was the anti collaborator won over by the pro side of the debate during the course of the project, or were they just less competent at research and argument, or was their side of the argument not given a fair hearing due to a more forceful personality on the part of the pro partner?

    • Radu Floricica says:

      > protective function of the foreskin against everyday minor abrasions

      I’m thinking we have underwear now, or more generally clothes. Before that yes, going through the bushes or doing rough physical activities with sensitive parts exposed would probably lead to auch and infection.

      • thinkingfor10minutes says:

        > I’m thinking we have underwear now

        Yes and it is unpleasant (or sometimes outright painful) to have the head of my penis (with the foreskin retracted) to be rubbing against the underwear.

        • Radu Floricica says:

          I noticed that one of the studies mentioned in the comments was controlling for underwear type. Means there’s a good chance you can find a better kind.

          • Aapje says:

            Silk panties. 😛

          • thinkingfor10minutes says:

            I still have my foreskin, so I don’t need a better kind of underwars. I am absolutely surprised at the lengths people go to downplay issues from circumcision.

            Yes, it is painful but it’s done to you as an infant so you won’t remmeber.

            Yes, it’s harder to masturbate, but you can use lube.

            Yes, the head of your dick may be less sensitive, but the studies show that there is no reduced sexual pleasure. [??? Is it even plausible]

            Yes, your dick is more dry and it may cause problems inserting it during sex, but you can use lube again.

            Yes, your dick will keratinize to compensate for constant rubbing against the underwear, but you might find better underwear.

            Or, you know, I could avoid having all those issues by not cutting my dick.

          • Radu Floricica says:

            @thinkingfor10minutes

            Except the painful part (it was done around 7 yo, maybe) I can’t really complain of any of the above. Obviously I can’t compare the sexual pleasure part. But I think it does lend niceley to experimentation, even if it’s hard to blind. I should try to wear a condom for a month and see if there’s an increase in sensitivity.

          • algorizmi says:

            Re: Radu Floricica’s adjacent comment.

            If you peruse any of the foreskin restoration sites the ‘dekeratinization’ process can take a good deal longer than 1 month but the effects are pretty obvious.

        • Purplehermann says:

          I am circumcised and do not have this issue, this may be a point for circumcision.

    • maintain says:

      I’d love to hear from the collaborators. Are you guys here? Can you comment?

  22. Rachael says:

    It would also have been nice to see some discussion of possible mechanisms for all of the health benefits (or a statement that we have no idea, if that’s the case). The authors did this for UTIs, but not for STIs or cancer.
    If it was observed that Jews have fewer STIs than Gentiles, I’d have thought that’s at least as likely to be because, as a traditional religious community, they were less promiscuous, than because of circumcision. Did the wartime physicians, or anyone since, compare the rates for non-circumcising religious communities, like the Amish or other traditional Christian sects? Did they compare practising religious Jews with secular Jews?

  23. samuelthefifth says:

    This post doesn’t address the title meaningfully at all. It is also a cop out unless the authors are willing to do exactly the same for female circumcision.

    After all, women suffer more UTIs, and the bacterial environment around their genitals is much more complex. Plus, seeing as it’s mostly women in Africa who perform the procedures, and who maintain the peer pressure to make other women in their society conform, surely we must stop being so narrowminded and consider that this procedure might in fact be beneficial?

    And then people will start coming up with reasons why it’s not the same. They say male circumcision is a safe and tiny nick, while female circumcision is outright mutilation… and then you tell them to look into how many men in South Africa had complications due to completely unsanitary tribal circumcisions in the wild, but it doesn’t register.

    They’ll say female circumcision is meant as a way to control women’s libido and sexuality, unlike for men. Yet here’s a long and dispassionate analysis whitewashing a procedure pushed onto the American populace by puritans who hated masturbation, considered backwards in many western countries, and which requires affected men to use artificial lotion for life just to enjoy a natural pleasure.

    But we all know what would happen if SSC would seriously investigate and consider the merits of the flipside, and hence why it will never be done. Not addressing this at all, as part of a post that claims to concern itself with the ethics of the matter, is cowardly and intellectually dishonest.

    Personally I think advocacy of male circumcision is just a symptom of the fact that all men have Stockholm syndrome, and will rationalize all the fucked up shit society does to them, because they know if they complain, they lose standing in the eyes of women. Once had a Canadian nurse tell me all boys should be circumcised, because of all the gross dicks she had seen. My response was “just boys, or girls too?” She sputtered, but couldn’t justify the double standard. Neither can this post.

    • thinkingfor10minutes says:

      I’m going to steelman this comment a bit. I think exploration of the benefits of Type Ia FGM (the removal of clitoral hood) is warranted when talking about male circumcision. Yes, other forms of FGM are much worse than male circumcision and therefore aren’t directly comparable. But removing the clitoral hood seems to be about the same as removing the foreskin? Does it have any benefits for women? Do such women have lower rates of STI?

      Do scientists in countries where Type Ia FGM is legal report any benefits of it? I think this could possible shine some light on pro-circumcision bias in western countries and how societies treat male and female body differently.

      • souleater says:

        I would be very interested in an adcolab on FGM/female circumcision. It’s never been clear to me if US cultural opposition to the practice is warrented or not.

    • ADifferentAnonymous says:

      Doesn’t FGM have a large and unambiguous negative effect on sexual pleasure?

      • thinkingfor10minutes says:

        Type Ia might not have any effect or have effect comparable to that of male circumcision. And yet it is also illegal.

    • “We don’t have data for X.”

      “Therefore, let’s ignore this data for Y.”

      “And whose fault is it that we don’t have data for X? Your fault!”

    • noyann says:

      seeing as it’s mostly women in Africa who perform the procedures, and who maintain the peer pressure to make other women in their society conform, surely we must stop being so narrowminded and consider that this procedure might in fact be beneficial?

      Find incomes for single elder women, and the practice nearly disappears.

      • keaswaran says:

        “Find incomes for single elder women, and the practice nearly disappears.”

        The same thing seems to be true of male circumcision, apart from the special case of the United States.

  24. jsmp says:

    If you have no foreskin, you have to get lube to masturbate instead. Many of us with foreskin are too sensitive to want a hand touching the head of the penis even if there is lube. Or even the inside of my underpants. Clearly this means increased sensation, how could it not?

    Making a utilitarian judgment based on just the few things that can or have been studied, and ignoring everything else, is scientism. And this piece is a bad case of it.

    • flame7926 says:

      If you have no foreskin, you have to get lube to masturbate instead.

      Not true.

      Clearly this means increased sensation, how could it not?

      Not sure sensation is necessarily linear in that way – it is possible both circumsized and un-have some level of “maximum sensation” while not being circumsized just makes you more sensitive sooner – which may not be a positive at all.

    • Adrian says:

      If you have no foreskin, you have to get lube to masturbate instead.

      Wrong.

      At least, wrong in general.

    • Ragged Clown says:

      I signed in to say the same thing.

      The business about “the foreskin is highly innervated” seems to me to be a distraction. With the foreskin retracted my glans is unbearably sensitive to contact. That’s unlikely to have anything to do with the number of nerve endings in my foreskin. Removing the foreskin must surely have some effect on the sensitivity of the glans itself.

      I wonder if the authors of the article have foreskins.

      • CompartmentalizedIdentity says:

        The glans penis becomes much more touch-sensitive when warded against minor sensory input (grazing against clothing, the legs, and so on) for long periods of time, so comparatively minor touch stimulus seems to be felt much more strongly when there is direct contact against the glans.
        This seems to imply that intact men will experience the ‘same orgasm’ from sexual practices that involve much less friction / movement to reach their orgasmic threshold, which means both in masturbation and in sexual play smoother motions, less use of the sexual partner as a source of friction, and many other subtle differences that affect the level of discomfort from penetration / movement of the receptive partner without changing their felt sexual stimulus.
        This is easily tested by performing oral sex on both cut and intact men, and I think is part of the divergent views between my MSM peer circles and the commenters in the rationalist and rationalist-adjacent communities.

    • If you have no foreskin, you have to get lube to masturbate instead.

      False, by direct experience.

      • Clutzy says:

        This is insanely false. I am circumcised, and didn’t know until this anti-circumcision movement appeared to me online. I could masturbate dry under a desk next to you while watching an execution and you wouldn’t notice.

        A lot of these sensation fanatics in the comments have really made me disinterested in their POV as a result. According to them I would ejaculate .5 seconds after entering a vagina if I wasn’t. This is an insane POV.

  25. eric23 says:

    I would have liked a more detailed and numerical summary of the health consequences – for example grouping them all into a total number of “disability adjusted life years” gained or lost, in Western and in non-Western countries.

    • Cliff says:

      This exactly. Where is the cost benefit analysis? Clearly getting HIV or having your penis cut off are extreme outcomes that matter much more than whether you get a UTI.

      • CompartmentalizedIdentity says:

        Failing to include NNT or using misleading comparisons of statistics feels like a form of motivated reasoning.

      • eric23 says:

        Clearly getting HIV or having your penis cut off are extreme outcomes that matter much more than whether you get a UTI.

        Not necessarily, if UTIs are much more common. But this needs to be quantified.

  26. joncb says:

    Could someone who has spent more time studying biology give a plausible explanation for how circumcision could directly reduce HIV infection rate? My current assumption is that result is being confounded (like perhaps men who get circumcised have less extra marital sex because they’re more religious?) because i can’t see how having less foreskin could in any way, shape or form restrict fluid transfer (which is my understanding of the mechanism for how HIV spreads).

    • jsmp says:

      Another possibility is that circumsized penises are less sensitive, thus it doesn’t make as much of a difference to put on a condom, thus a higher proportion do it. As you say, there is not really any plausible biological mechanism.

    • Aapje says:

      The theories I’ve seen is that:
      – the skin that is removed is thinner and thus more permeable
      – that the foreskin traps the HIV virus and thus prolongs contact

      • jsmp says:

        Also I didn’t read this part of the post before commenting. And it’s surprisingly convincing, I must admit. Even goes against my guess.

      • Dynme says:

        I would add that the foreskin has a decent concentration of Langerhans cells, which are immune cells susceptible to HIV infection. If anything, I would expect the infection rate of other diseases to go up due to circumcision, but I’ll grant that there may be other factors at play that offset removing a bunch of immune cells.

    • d20diceman says:

      The post referrers to randomised trials finding reduced rates of HIV, so the “more/less religious” confounder shouldn’t apply in those circumstances.

  27. Robert Jones says:

    As others have said, for a collaboration on whether circumcision is ethical, the writers spend surprisingly little time talking about ethics. From memory, last year’s collaboration on vaccination went into a lot more detail about the ethics of infant interventions generally.

    In the case of a competent adult, hardly anyone says that we can ignore consent because a rough utilitarian calculus suggests the intervention is net positive. So why is the situation different for infants? The authors say, “From a strictly utilitarian perspective, infant circumcision should therefore be encouraged,” but why do they stop short of saying it should be mandatory? There seems to be a tacit assumption that parents are able to decide for their children one way or the other, but why should this be the case?

    Even within a strictly utilitarian framework, we should probably assign some value to respecting the principle of bodily autonomy, because we don’t wish to live in a world where we fear being cut up for parts if the calculus shows that to be a net benefit. It seems to me a reasonable position (and in practice a common one) to say that bodily autonomy is important but can be sacrificed in order to avert a sufficiently serious harm, and in that sense the final paragraph is a cop out, because it makes no attempt to weigh the medical benefits against the violation of bodily autonomy.

    • maintain says:

      Thanks. I was looking for a way to say that politely, but I think you nailed it.

      I’m opposed to infant circumcision, but in order to keep it fair, I’d also like to steelman the other side, and say that we should take into account the huge amount of suffering that would be caused by an infant circumcision ban. Imagine being an orthodox Jew, having a son, and not being allowed to circumcise him, the way all the other men in your family are circumcised. Imagine having to look at your own son every day, with his disgusting foreskin, every time you change his diaper–just being reminded every day, and never having it go away… your own son! …In your own house! I imagine it would feel incredibly violating on a personal level.

      When we start talking about the emotional suffering on either side of the circumcision debate, the amounts of suffering absolutely swap any trivial fraction-of-a-percent protection from STIs.

    • flame7926 says:

      Well I think parents violate their children’s bodily autonomy all the time in ways that would be inappropriate to do to adults – from changing them to giving them shots to picking them up without their consent to piercing their ears to cutting their hair.

      So I think we can’t assign children and particularly not infants the same right to bodily autonomy as we do the general population.

      • Robert Jones says:

        This is true. Children are not adults. But we also do not allow parents unfettered rights to treat their children in any way they choose. What is required is some analysis of the appropriate scope of children’s/infants’ bodily autonomy and of parental behaviour.

        • Purplehermann says:

          May I suggest that parents can make choices which are consequentialistically a net positive, and lose value by being deferred to a later date?

      • cuke says:

        Most parenting takes place in the vast gray area between “I say for you” and “you say” — the whole journey is one long process of turning over the reins. That makes consent and autonomy central themes in accompanying children to adulthood. So for me, that we violate children’s autonomy all the time doesn’t clarify anything about this issue.

        Very young children will express opinions about being picked up and having their hair cut. Almost from the very start, parenting becomes a process of weighing values like autonomy against values like expediency, or values of growth/learning against efficiency. It seems to me what guides us is clarity about how we prioritize these competing values, which is going to vary from one parent to another.

  28. thinkingfor10minutes says:

    The pro-circumcision side arguments may be well-represented, but anti-circumcision side seems like a weakman. I’m uncircumcised and come from a country where it isn’t routinely performed. I agree with what Rachel, onyomi and ana53294 said.

    1) There is no exploration of the ethical aspect. Both collaborators seem to be utilitarian. I’m not, but I’ll try to present a different utilitarian argument. We can observe utility functions of adults. How many informed adults choose to get circumcised? If the percentage is small then clearly the utility of not getting circumcised for them is higher. The costs of circumcision outweigh the benefits for them. Personally, as an adult, I have zero desire to get circumcised.

    Why impose those costs on infants? Maybe circumcision does not affect infants as much as adults but in the past it was commonly believed that infants don’t feel pain until they are 1 year old. IIRC even surgeries were performed without anaesthesia on infants. Maybe circumcision is somehow different and babies recover faster, don’t feel as much pain, etc — but there was no exploration of that.

    2) There is no exploration of benefits of foreskin restoration. Some people choose to try to restore their foreskin, for example, by stretching the remaining skin. While it’s not going to have the same nerve endings it is going to provide some of the protective benefits.

    • flame7926 says:

      Why impose those costs on infants? Maybe circumcision does not affect infants as much as adults but in the past it was commonly believed that infants don’t feel pain until they are 1 year old. IIRC even surgeries were performed without anaesthesia on infants. Maybe circumcision is somehow different and babies recover faster, don’t feel as much pain, etc — but there was no exploration of that.

      How much does pain matter if there is no solid memory of it? I would think the answer would be a sizeable deal less than pain which there is a lasting memory of.

      I would also imagine that the utility calculation for an adult looking to become circumcised is much different than one looking back and wishing they either were or weren’t. Like I would never decide to learn Russian or play violin – too time consuming, not worth the effort. But I wish my younger self had dedicated the time to, or had been cajoled or otherwise brought to do it by my parents.

      Basically, I don’t think we can extrapolate from people’s present utility calculations to determine whether something should be done to a non-analogous and relatively non-autonomous being.

      • onyomi says:

        But we also probably don’t fully understand how early experiences may shape an infant’s later psychological makeup. Given that, seems a precautionary principle is in order, rather than just “he seems fine!” especially for a surgery that just isn’t medically necessary for most. The comparison elsewhere to vaccines is also not reasonable, imo. It’s not like you go to an 18th c. cemetery and ponder sadly all the countless tiny victims of phimosis.

        • GearRatio says:

          This is somewhat off topic, but a good example of why I hate how the precautionary principle is often used. A probably strawman of how I’m reading your post goes like this:

          1. I see your evidence that this causes real benefits for a significant amount of the people who have it done/done to them, but I’m going to say “but this doesn’t benefit most people” to ignore those it does benefit.

          2. I can’t or won’t or don’t provide actual evidence this causes harm to counter your evidence of benefit, but I’m going to say there might be.

          3. I’m going to imply or out-and-out say that 2 should outweigh 1.

          Let me repeat this is probably a strawman of your statement. I’m sure you have more/better, this is a short post you made, I’m not saying this is your actual position.

          With the bold out of the way, this is the actual way vaping has worked out:

          1. Hundreds of thousand to millions of people are screaming that vaping has helped them quit cigarettes. They are flat-out-ignored; only controlled study results which omit all the cultural parts that help (vape shops, help from other vapers) and use people who haven’t selected the vapes/flavors they like themselves and are losing the “customization bonus” are listened to. Even where the latter kind of data is acknowledged, it’s discounted.

          2. There’s no credible in-vivo show of harm to any living human from using e-cigarettes; it’s all “we had mice swim in e-liquid or put exposed lung tissue in an e-liquid bath in a dish” type stuff, and even then the effects are questionable. Still, this is proof positive e-cigarettes are deadly killers. We also talk about trace amounts of chemicals present like we’ve considered the harmful dose amounts, but we haven’t and won’t acknowledge the problems of a harmful dose have failed to materialize.

          3. Public health’s vast majority opinion is that we need a ban now, this very second, based on the precautionary principle and very much not based on listening to the many people screaming that they use them and they help.

          Summary: I hate the precautionary principle and think it’s a De Facto way of saying “I don’t have any evidence what I want should happen, but you are damn well going to get it anyway and you better pretend to like it”.

          • onyomi says:

            I agree I don’t like when the precautionary principle is invoked in such cases as vaping: when it comes to taking choices away from adults I think one should err on the side of letting people make their own choices, especially if they’re only likely to hurt themselves.

            And while I might also invoke it wrt the overall advisability of the surgery (here we are taking away a choice from the adult man, one most seem not to think worth it when they are able to chose), I was here invoking the “precautionary principle” idea in regards to the infant psychology issue in particular: which is to say, when it comes to something I don’t think we understand super well, such as how painful experiences in early life affect later development, I think we should err on the side of assuming they can be harmful rather than of “he stopped crying and now he seems fine, so no harm done!”

          • GearRatio says:

            I agree it changes somewhat when we are talking about doing something to an infant. With that being said, I’m definitely the type that will abandon all precautionary principle at the first sign of the smallest data-point against it – I.E. the discussion above shows a real benefit to circumcision, so “this might be a problem” gets immediately beaten by “there’s a definite, real benefit” for me.

      • thinkingfor10minutes says:

        I would think the answer would be a sizeable deal less than pain which there is a lasting memory of

        Possibly, but this wasn’t explored at all. I don’t know what psychology says about about memories, but it’s possible having a memory consciously accessible would allow easier updating on it.

        I think there is a term ‘preverbal trauma’. I don’t know if it is a valid concept and I don’t know if it can arise from surgeries (including circumcision). But if it is, it should be taken in account.

        Case somewhat in point on pain and memories. I am from one of ex-USSR countries where it was really common to treat tooth cavities without any anesthesia (because fuck you that’s why). I don’t have much memories about that. In fact all my current consciously accessible memories are after the time my parents got sensible and started paying extra for anesthesia. Yet to this day I have strong aversion to going to dentist. It usually subsides once I actually get in the chair and the treatment begins.

        I don’t have recollection from the first dentist encounter at 3 y/o, but my parents told me at a later age that I absolutely hated it and there was a ton of pain. By the time it was the second time to go to the dentist, I had no conscious recollection of dentists at all but still hated the idea of going to the dentist.

      • thinkingfor10minutes says:

        Like I would never decide to learn Russian or play violin – too time consuming, not worth the effort.

        And a lot of people are forced to learn an instrument as children and then hate playing it as adults. Same with foreign languages.

        I am not entirely getting your point here. Is forcing circumcision on all current adult males would be good, because a lot of them would be grateful in the future once they pay the costs of it? (Again, there may be significantly more costs for adults, but the collaboration didn’t discuss it).

      • devonian22 says:

        How much does pain matter if there is no solid memory of it?

        For some operations (e.g. wisdom tooth extraction), patients are given midazolam to sedate them. It also has the handy effect of wiping your memory for the duration. Suffice it to say, I think you’d still want an anaethetic while you’re being operated on.

        I wonder: if infants could remember the ordeal, would the conversation around the harms/benefits of circumcision be so sanguine?

        • Jacobethan says:

          To all appearances, there is no “ordeal.”

          But to answer the question, yes, the conversation takes the particular shape it does (with “What’s the harm?” being a kind of cultural default position) because for neonates any distress appears negligible and there is no subsequent recall of the event to contradict that impression.

          In some counterfactual universe where neonate psychology was totally unlike how it actually is, then yes, we’d probably make a whole host of decisions for babies very differently in order to minimize a very different set of potential psychological harms. In the real world, I’m not sure we even have a clear notion of what it would mean to “remember” something in the context of a presumably nonrepresentational consciousness.

          • devonian22 says:

            To all appearances, there is no “ordeal.”

            Says who? Lander 1997 is a study on pain relief in neonatal circumcision and found that even with a skilled surgeon, “every newborn in the placebo group exhibited extreme distress during and following circumcision”. They had to stop enrolment mid-way through the trial because it was clear that adding to the placebo group would be unethical.

          • Jacobethan says:

            Vide supra my response to your citation of that study in your conversation with David Friedman.

            Perhaps saying “no ‘ordeal'” was too glib of me. It’d be more accurate to say it looks to me like an ordeal on a similar level to many other slings and arrows of daily existence that are also, in a very real sense, ordeals for newborns. I’m just skeptical that circumcision rises in some distinctive way above the general terrain of episodic stressors that infants have to navigate all the time.

          • devonian22 says:

            I’m just skeptical that circumcision rises in some distinctive way above the general terrain of episodic stressors

            What evidence, then, would you need to see to convince you that cutting off part of a newborn child’s penis without pain relief is more painful than being hungry, or colicky, or tired?

          • Jacobethan says:

            In the Lander study you cited they use a few simple behavioral and/or physiological signs as proxies for degree of discomfort (duration of crying, heart rate, palm sweat, etc). So a reasonable starting point would be to ask how what they observed for the various circumcision groups compares with the typical range for “normal” distress episodes among same-age infants. I don’t honestly know what the answer would be, but I gather you have a good sense of what my prior is.

            That said, as I type this I realize I’m not sure if that quite addresses what you’re asking. Maybe you’re trying to point to a certain kind of qualitative experience that’s specifically *pain*, and that under some moral frameworks one might perhaps care about differently from, e.g., frustration (even if both produce quantitatively equivalent levels of subjective discomfort)?

      • Peter Gerdes says:

        Might as well say how much does pain matter at all given we will all die and then forget about it.

    • Jliw says:

      In addition, as a few other commenters have pointed out, this collaboration missed some studies on loss of sensitivity; I also remember reading a few about possible reasons for the protective effect re: HIV that questioned its utility in more developed countries, but I don’t recall the reasoning. Still, I’d have liked to see a more in-depth discussion.

    • Purplehermann says:

      As to 1) I’d like to know how adults generally act, but let’s assume most uncircumcised adults don’t get it done.

      I don’t think most people seriously consider things not prevalent in their cultures, so let’s assume we find most people uncircumcised at the age of 16 (arbitrary yes), in cultures where circumcision is perfectly normal and it’s weird not to be, never get circumcised.

      It is clearly better to get circumcised as an infant if you’re going to do it, why would adults generally choosing against doing it mean they wouldn’t choose to have been circumcised as a child if they could choose now.

      Adults make bad choices all the time when it comes to pain, fear and inconvenience (doctor checkups are pushed off, they eat badly, etc etc etc.), when it comes to an operation that is scary(cutting my penis!??? Hell no!), painful (I assume it’s painful, I don’t remember mine) and inconvenient (maybe disturbing too?), on top of most people not actually knowing the benefits and positives, people choosing not to be circumcised means nothing in terms of actual utility, IMO.

      • thinkingfor10minutes says:

        You are missing the point of my argument. People often choose to get their wisdom teeth removed. It’s a painful procedure so sometimes people push it off. However, the existence of significant number of people who get it done for medical reasons seems to imply that wisdom teeth removal gets them positive utility. Perhaps the actual number of people who will benefit from this procedure is higher, but even the current number is substantial.

        People rarely choose to remove their left pinky to reduce the risks of left pinky cancer. Therefore we can conclude that left pinky cancer brings people negative utility.

        Is circumcision more like removing left pinky or more like removing wisdom teeth? We can look at the number of people who get circumcised as adults to reduce minor risks. Does circumcision look more like left pinky removal or like wisdom teeth removal?

  29. fion says:

    Well done both of you!

    I think my main criticism of this is that you downplay the importance of pleasure from masturbation. It seems that circumcision reduces some already rather low risks and doesn’t reduce pleasure from sex, but does reduce pleasure from masturbation. Well I don’t care much about reducing the risk of something I’m not likely to get anyway, and I only have sex like once a week so that doesn’t matter much either. But I masturbate every day and it’s the most pleasurable part of my day, so even a modest reduction in pleasure is a big deal!

    • GearRatio says:

      This applies pretty well to the “don’t get circumcised as an adult” argument, but probably less well to the “don’t get circumcised as a baby” argument. I’m not sure I’m observing any significant amounts of adults-who-were-circumcised-as-babies-can’t-masturbate data, and it would be pretty easy to get by comparing countries where infant circumcision is popular(the US) to countries in Europe where it’s not.

    • EchoChaos says:

      I was circumcised as an adult, and there is no difference between pre and post circumcision for this.

  30. Steven says:

    I was really disappointed by this.

    I didn’t get the sense that there was anything “adversarial” about this collaboration at all. It seems that the only purpose the anti-circumcision side served was to demand that every number quoted had a study to back it up. There was little questioning of the figures, or the interpretation of the figures, and very little discussion of ethics at all. I completely agree with user Mention’s comment in this regard.

    In the very first section on penile cancer, there seems to be no recognition of the fact that a surgical intervention applied to an entire population is an extreme way of reducing the risk of a rare form of cancer. It may give a 90% reduction in incidences of penile cancer, but that only reduces the incidences from 400 per year to 40 per year in a population of 164 million. As user Onyomi mentions, this scope insensitivity could lead someone to suggesting offering pre-emptive double mastectomies to all women to reduce breast cancer.

    Let’s actually look at the numbers sensibly (as the anti-circumcision collaborator should have done) and see where we get to.

    US male population of around 164,000,000, with around 2,000,000 male births per year.

    Circumcision would reduce penile cancer incidence from 400/yr to 40/yr.

    There are around 26,000 new cases of HIV per year in the US, ~7% of which are due to heterosexual transmission, giving us 1,820 relevant cases per year. Circumcision is claimed to reduce heterosexual transmission of HIV by 50%, so let’s take that at face value and say that if men in the US stopped being circumcised, this would double to 3,640/yr.

    Of the 2m male births per year, 0.2% experience major complications with their circumcision – this gives 4,000/yr.

    Taking the figures from New Zealand, 1.8% of people without a circumcision experience some sort of issue that requires intervention later in life, and the collaborators suggest that 6% of adult circumcisions experience complications. 2m births per year x 1.8% x 6% gives us approximately 2,160 adult circumcision complications per year if nobody was circumcised.

    This covers death and major complications, so how does that stack up?

    On the circumcision side, we have 40 cases of penile cancer, 1,820 cases of HIV and 4,000 major surgical complications, giving 5,860/yr.
    On the anti-circumcision side, we have 400 cases of penile cancer, 3,640 cases of HIV and 2,160 major surgical complications, giving 6,200/yr.
    This is hardly what I would call conclusive – circumcision seems to reduce your risks of these serious issues from 0.31% to 0.29%.

    Let’s look at the more minor complications though – maybe there is more benefit there:

    UTIs in the first year of life are reduced from 1% to 0.1%, so for our 2m births per year, circumcision gets us 2,000 UTIs per year, and non-circumcision gets us 20,000/yr.

    There are minor surgical complications to infant circumcision in 1.5% of cases, giving us 30,000/yr.

    Again using the New Zealand figures, we have later complications for uncircumcised people at 1.8% and for circumcised people at 1.1%. Multiplied by 2m male births per year to give us an annual figure, this gives 36,000/yr for uncircumcised, and 22,000/yr for circumcised.

    Let’s add these ones up:
    Circumcised – 2,000 + 30,000 + 22,000 = 54,000
    Uncircumcised – 20,000 + 36,000 = 56,000
    Once again, pretty inconclusive – circumcision seems to reduce your risks of more minor issues from 2.8% to 2.7%.

    Surprise, surprise – the benefits and drawbacks of circumcision are pretty much equal, and there isn’t a knock-down medical argument for either side. This probably explains why it is a debate that continues to rage in so many different spheres. It really does come down to whether you think that a child’s bodily integrity and ability to make choices later in life and are more important than an adult’s freedom to control their children’s environment or not.

    Full disclosure, in case it wasn’t obvious – I am on the “child’s bodily integrity and ability to make choices later in life” side. I can’t help but feel that the adversary to circumcision in this case was less bothered by those considerations, and more just “meh – I don’t really see the benefit, so I guess I’m against it”, and once they had been barraged by enough sufficiently convincing sounding studies, just stopped being adversarial.

    • Robert Jones says:

      I can see some problems in your analysis (in particular treating penile cancer, HIV and major surgical complications as interchangeable) but I agree that an analysis like this is required to make good the authors’ claim that circumcision wins on a purely utilitarian perspective. Also, given their conclusion that they “reasonably fear that there is some decrease in at least masturbatory pleasure due to circumcision”, that needs to be included in the calculus. I agree with fion that the authors seem to be downplaying this.

      • Steven says:

        You are of course quite right, however in my defence, that was just what I could knock together over my lunch break. I felt that “serious, life changing problems” and “minor, unpleasant events” were sufficiently unambiguous bins to combine things into, to give a reasonably quick calculation.

        There are plenty of other aspects that I probably could have dug deeper into, and that really should have been touched upon in the collaboration:

        Have the HIV transmission statistics been properly controlled for religiosity? There may be a correlation between circumcision and being less promiscuous, if both are correlated with high religiosity.

        Is the 50% reduction in HIV transmission found in Uganda and South Africa directly comparable to countries such as the US? Different cultures around hygiene, prophylactics and having multiple partners could change this figure dramatically.

        Cancers can be highly heritable – are the penile cancer statistics adequately controlled for the possibility that Ashkenazi people may have genetic factors that reduce its prevalence?

        Aside from the mentioned effect of circumcised people using condoms less, due to feeling “safer”, are there any other considerations pushing circumcised people away from condom usage? Even if the difference in sensation during unprotected sex is negligible, I have read that there may be a significant difference in sensation when wearing a condom, which may discourage circumcised people from practicing safe sex. The much more positive opinions on condoms in Europe vs. in the US may just be circumstantial, but there could be causation there.

        Are there any studies on the health effects of Type I FGM? I for one wouldn’t care even if there were slight positive effects, as even the most minor type of FGM is barbaric, but then… so is male circumcision. There is more to utilitarianism than looking at the most immediate, obvious consequences – what are the consequences of having a society that doesn’t care about respecting and developing their children’s autonomy and independence?

        Is there a danger of reinforcing problematic societal attitudes, or pathologizing perfectly healthy people? Some Americans view an uncircumcised penis as “unclean”, regardless of the person’s personal hygiene, probably largely because of this kind of motivated reasoning. Could better hygiene education perform a similar but much less invasive public health purpose?

        All of these are questions I would expect to see addressed in any serious attempt to wrestle with this issue, and the studies put forward.

    • S. Aiv says:

      This is exactly what I was thinking reading the piece. Thanks for doing the math, so I don’t have to.

    • Jon S says:

      Penile cancer currently kills 400 Americans per year, even though most of the male population is circumcised. Perhaps the all-circumcised vs all-not numbers would be more like 120 vs 1200 (I’m guessing, but it’s definitely more than your 40 vs 400). Presumably there are also many men who suffer from penile cancer but survive – the article doesn’t break this down.

      I agree with Robert that some of the categories you’re comparing raw numbers for aren’t 1:1 equal.

      • DeWitt says:

        I agree with Robert that some of the categories you’re comparing raw numbers for aren’t 1:1 equal.

        That seems like a fair point to make. It is also one the article entirely neglects to consider. It is similarly fair to call the article out on not being a good one when it doesn’t even seem to really try.

      • Aapje says:

        Penile cancer killed 137 men in the UK in 2016, for a population of 66 million.
        The US population is about 325 million.

        137/66 = 2.08 deaths per million in the UK
        400/325 = 1.23 deaths per million in the US

        8.5% of UK men are circumcised vs 75% of US men.

        Note that environmental differences seem to influence the prevalence, so the gap doesn’t have to accurately reflect the protective effect of circumcision.

    • cuke says:

      Thank you, I found this incredibly helpful. And I agree with you that the lack of clear, overriding health benefit for a surgical intervention means that other factors drive people’s decision-making on this issue and that for many who choose not to circumcise, that the value of autonomy is key.

    • Thegnskald says:

      The study I think likely to contain the information is behind a paywall, but I am curious what the figures look like if you count the number of interventions necessary, excluding medically necessary circumcision.

      I suspect the “complications” figure looks a lot different if you exclude cases where circumcision is the corrective action taken, since in a significant sense we are counting interventions in the uncircumcised column we aren’t counting in the circumcised column.

      ETA:

      That is, if we measure by interventions, rather than “complications”, we either have a significantly lower rate for uncircumcised, or a 100% rate for circumcised.

    • devonian22 says:

      Thanks. This was a much better analysis than the actual post was…

  31. indigo says:

    Was this, in fact, *adversarial* in any way?

    • maintain says:

      Last year, I tried to do an adversarial collaboration, but every partner I found ghosted on me. This year I didn’t even bother trying. The majority of people who say they are going to collaborate end up ghosting.

      My hypothesis of what happened here:

      The anti guy ghosted the pro guy, but the pro guy wanted to enter the contest anyway, so he tried his best to write an unbiased article. However, he wasn’t as unbiased as he thought he was, so the article turned out kind of weird.

  32. Thegnskald says:

    Like other readers, I’m left wondering what influence the anti-circumcision participant had, if any; right now it looks like that participant suggested a decrease in pleasure, couldn’t find any research, and so got a comment saying it was important but unresearched.

    Suppose it decreases sexual pleasure. Is it reasonable for anyone other than the individual concerned to make that decision?

    Suppose it increases sexual pleasure. Again, is it reasonable for anyone other than the individual concerned to make that decision?

    Castration has much stronger health benefits. By the criteria of this article, castration should.be promoted. Now, if you are pro-infant-circumcision and anti-infant-castration, consider carefully your reasoning, and when you decide that personal autonomy matters, and why, and tell me what the difference is.

    • EchoChaos says:

      Now, if you are pro-infant-circumcision and anti-infant-castration, consider carefully your reasoning, and when you decide that personal autonomy matters, and why, and tell me what the difference is.

      The difference is that circumcised individuals can still reproduce and castrated individuals cannot.

      • Thegnskald says:

        And why is that relevant?

        If you think the relevancy is too obvious to explain, explain it anyways.

        • EchoChaos says:

          And why is that relevant?

          Because the first commandment given to man is to be fruitful and multiply.

          • Thegnskald says:

            And the seventh says not to steal, yet here we are taking something far more valuable than property: Choice. (And flesh, but who is counting?)

            I mean, it’s not like the gift of free will is super-important, or anything like that.

          • EchoChaos says:

            @Thegnskald

            And the seventh says not to steal, yet here we are taking something far more valuable than property: Choice.

            Parents steal childrens’ choices all the time. This is entirely normal.

            And if you’re trying to sway me using deontological arguments from the Old Testament you are going to definitely lose on this one.

          • Thegnskald says:

            Granted.

            So what if another religion says boys should be castrated? Elsewhere here you indicate parents should have near unlimited power, particularly for religious beliefs purposes.

            Do you support the parental authority there?

          • EchoChaos says:

            So what if another religion says boys should be castrated?

            That religion doesn’t exist, and for obvious reasons wouldn’t last long.

            Elsewhere here you indicate parents should have near unlimited power, particularly for religious beliefs purposes.

            Indeed. This is one I’d draw the line on were I making the laws, just as I would forbid a believing Aztec from sacrificing his son to placate the gods. Fortunately, we eradicated the Aztec religion and no “castrate” religion exists.

          • Thegnskald says:

            Which brings us back to the earlier question:

            What makes infant castration different from infant circumcision, such that you are comfortable banning one but not the other?

            From my perspective, the reasons are cultural; circumcision is normal to you, castration is not. More, I would guess you feel the function of the testicles is in some sense morally relevant in a way that the function of the foreskin is not. I’d furthermore guess you don’t have personal experience in the function of a foreskin, where you do have personal experience in the function of testicles, and so one feels like a nothing, where the other is something you take for granted and thus would feel a sense of loss about.

          • EchoChaos says:

            @Thegnskald

            I am pretty sure I’ve answered that question, so I’m not sure why you’re asking it again.

            Because God commanded one and God forbids the other.

            I’d furthermore guess you don’t have personal experience in the function of a foreskin

            You are incorrect. I was circumcised as an adult.

          • Aapje says:

            Actually, a castration sect did exist in Russia, with estimates of up to 100k followers.

            Link is NSFW for having a picture of a castrated man and a woman with a mastectomy.

          • Thegnskald says:

            So your idea of religious freedom is “Things compatible with my religion”?

            ETA:

            Imagine I am emperor. You are one of three petitioners before me; another belongs to the Anti-Circumcision Cult, and the third belongs to the Church of the Feminazi.

            The ACC argues both circumcision and castration violate the tenants of their faith, and should be banned.

            You have argued that circumcision should be allows, but castration should.not, based on the tenets of your faith.

            The representative of the Church of the Feminazi doesn’t care about circumcision, but cares deeply about their religious right to castrate four fifths of all male-born children, in accordance with their religious principles.

            What makes your case special?

          • EchoChaos says:

            @Thegnskald

            So your idea of religious freedom is “Things compatible with my religion”?

            Yes, and some margin within reason.

            It is an unquestionably good thing that Christians eradicated Aztec worship, Norse worship, etc. Do you think that the right of the Druids to sacrifice humans (some consenting, some not) should be allowed in modern society? If not, why?

            In terms of law, my case is enforced because the majority of my country agree with me, which is the traditional method of deciding when two moral systems have irreconcilable claims.

            In terms of morality, it’s special because it is supported by Scripture.

          • Thegnskald says:

            Echo –

            Unfortunately I am committed to arguing for your religious freedom with everyone else’s, but if I could make an exemption that you, specifically, can be forced to bake gay wedding cakes, I would, since you’ve just stated those are the principles you think should govern us, and I think people should live under the systems they would design for others.

          • EchoChaos says:

            @Thegnskald

            Unfortunately I am committed to arguing for your religious freedom with everyone else

            I suspect you’re probably not, you just have further boundaries than I do. And of course you are against my religious freedom to circumcise my son on the eighth day as I am commanded to do.

            but if I could make an exemption that you, specifically, can be forced to bake gay wedding cakes, I would, since you’ve just stated those are the principles you think should govern us, and I think people should live under the systems they would design for others.

            What vote was ever taken on whether or not people should be forced to bake cakes for homosexual weddings? If you’re referring to Supreme Court decisions, those are not popular votes. All popular votes I’m familiar with went my way, which is why our elites overrode us.

            As for the limits, should a proprietor be free to ban gays based on religious beliefs? What about Muslims? Blacks?

            Should Druids be allowed to engage in the voluntary sacrifice of putting someone in the Wicker Man?

          • Erl137 says:

            It is an unquestionably good thing that Aztecs eradicated Christian worship. After all, Christians burned countless people alive for being “witches” (not a real thing) or heretics. In fact, the Christians would conquer a religiously heterogenous territory, force everyone to convert to their religion, and then torture and murder any of those “converts” who practiced their traditional religion in secret.

            Of course, in the Medieval period, we Aztecs had practices we don’t follow today, such as the sacralized execution of captured enemy soldiers, or the voluntary assisted sacrifice of saints and ascetics. But really there’s no comparison.

            Do you think that the right of the Priests to burn unconsenting humans alive should be allowed in modern society? If not, why?

            (I myself don’t hold to such a sunnily Aztec take on the practices of the Triple Alliance. And some important details have been elided above. But the comparison was crying out to be made.)

          • EchoChaos says:

            @Erl137

            Thanks, that got a smile from me.

        • Purplehermann says:

          First off, vast majority of humanity highly values their ability to reproduce, I think most people would be horrified if their parents had even considered castrating them, with circumcision most people really wouldn’t be bothered, and many are glad. This should at least signal a difference.

          People care more about losing an entire function, than about changing the intensity of a function.
          If circumcision completely cut off sexual pleasure the comparison would be much better.
          Even then, reproduction is in my opinion a much more basic and important function.
          Sexual pleasure is mostly a piece of the general reproductive system, cutting off the main point of the system seems more problematic than a smaller piece.
          We are programmed biologically (in general) to care a lot about creating a continuation of ourselves, taking that away from someone is taking an important piece of who they are/could be.
          Sexual pleasure by contrast is an important footnote.

          • Thegnskald says:

            That’s an argument that there is a difference in degree, but not necessarily a difference in kind. I happen to agree, except about the part about people being horrified, because in an analogous situation, in which it was regarded as normal, I think the emotional reactions would be pretty neutral on average.

            What makes it substantively different in nature, such that you think one is acceptable and one is not?

    • AlexanderTheGrand says:

      I can say with high confidence that a child raised in the Western world would be more likely to resent their society for allowing their castration than their circumcision. Because of changes to hormones, loss of fertility, MUCH stronger social stigma, etc. They’re both irreversible choices made for a baby, but given everything I know about the world we all inhabit, one is a much larger choice than the other. And we’re allowed to take this real-world biases into account, because our kids are going to be living in that world.

      Two things can be of the same kind but different degrees. Stealing a paperclip vs stealing a car for example. Do you actually believe the two things you listed are the same? Would actual you, not platonic-ideal you, judge a parent equally for doing both?

      Now, a rhetorical question for you: should a parent get to decide whether they repair a child’s cleft lip and palate? Let’s say we live in a world where the health effects are minimal, but you just KNOW their life is going to be harder for societal reasons if you leave it as is. (To be clear, I’m not saying uncircumcised men have a harder time in the world now, I’m making the point that the issue of personal choice and the issue of societal harm from castration can be put on the same scale to be compared).

      • Thegnskald says:

        I grant the real-world biases, and assent that I would judge the parents differently. But within those who choose to circumcise, there are measures of difference yet, based largely on whether they should have fucking known better.

        What I judge harshly is the culture, which treats men’s bodies as belonging to anyone but themselves. It is a culture of ignorant savages, and it is useless to blame those who know no better.

        At a certain point, when they know better, I stop distinguishing between the cases.

        As for cleft palattes, and similar issues, I am too ignorant to make a strong statement. My limited statement is that there is a qualitative difference between the best available correction to dysfunctional development, and the alteration of functional development. Yeah, “functional” is doing some heavy lifting there; broadly I mean “Does the thing do what it is supposed to do”. There is a fuzzy boundary around how well it does it, and when that impairment becomes significant enough to require or permit intervention, which I think can’t be written as a bright line rule.

        So I’m okay with a child having an infected tooth removed, forcefully if necessary. I am not okay with that force being applied to a child whose teeth will merely be slightly overcrowded, and unaesthetic. Okay again with it if the overcrowding is severe enough; there’s another fuzzy boundary there in terms of what constitutes severe enough, but I am okay with fuzzy boundaries.

        • What I judge harshly is the culture, which treats men’s bodies as belonging to anyone but themselves.

          I’m puzzled as to how people with this position or the closely linked “bodily autonomy” position justify the vaccination of children, a point others have raised but I don’t think anyone has answered. In practice, as with the comment I’m responding to, people seem to alternate between an absolute non-consequentialist rule, used to rule out circumcision, and a consequentialist rule, which amounts to “it is all right to violate the non-consequentialist rule if the consequences are positive and significant.”

          I have some sympathy with non-absolute non-consequentialist rules, which would give that result, but that isn’t the language that Thegnskald and an Firenne and various others are using.

          Let me take another example. “Bodily autonomy” presumably includes the right to control your own body, as long as you are not injuring others — a standard libertarian position. What if your two year old wants to walk into traffic, or pet a large dog that is snarling at him?

          • Thegnskald says:

            I’ve responded to the vaccination consideration; I think government can reasonably force vaccinations, but parents cannot.

            My reasoning here involves a parallel to whether I think government can forcibly quarantine somebody with an infectious disease, and I think this is something government ought to be able to do, in specific violation of bodily autonomy and rights more generally.

            Which is to say, I think forced vaccinations by government amounts to a form of quarantine, a power I think they should hold.

            The parental interest, in either case, is substantively weaker (in most cases), and so bodily autonomy wins.

            I analogize below, to a child, with an undeveloped brain, being analogous to a comatose patient. If it would be unacceptable to do to the patient, why is it acceptable to do to a child?

            ETA:

            As for children running into traffic or playing with dangerous animals, perhaps the ward of a mental institution would.make a better analogy

            In general, I think it is appropriate to view parents as caretakers, not owners, of children.

          • cuke says:

            For me, this question is about what’s the bar? Meaning, how clear is the benefit up against the cost/risk?

            The case of circumcision looks too close to call on the material benefits, and the cost to autonomy is high (irreversible surgical procedure), so autonomy wins.

            The case of vaccination, the benefits are much clearer, and barring a rare and irreversible vaccine injury, most of the harms are temporary or reversible. In the case of our child, for instance, they had an out-sized reaction to one of the early immunizations (by CDC standards), their reaction was even bigger to the second scheduled immunization, and the doctor counseled waiting until the child was older to complete the series. So there was opportunity to respond along the way to more rare reactions in a way that reduced risk while still preserving most (and later all) of the benefit.

            Parents are going to weigh these things differently, but for me, circumcision lay on one side of the cost/benefit analysis and vaccines on the other. “Bodily autonomy” isn’t a value held to the exclusion of all others, including to the point of allowing a child to run into traffic because they feel like it. It’s a value to be weighed against other values. Harm prevention is a pretty big value too.

          • devonian22 says:

            Agree with @cuke. The benefits of circumcision are marginal; lots of medical bodies have stopped recommending it be done routinely for this reason. The benefits of vaccination – and of mass vaccination especially (through herd immunity) – are enormous.

  33. ana53294 says:

    About religious freedoms: I know the US is a country that values religious freedom exceptionally, as well as freedom of speech, and that’s great, power to them. But in a lot of european countries, that’s not the case, and I am not sure where the line is in favoring some religions vs others by banning some religions’ practices vs others.

    In Spain, though, a law was introduced that means Jehova’s witnesses cannot refuse blood transfusions to their kids. You don’t even need a judge anymore; a doctor’s decision that the life of the child is threatened means they get a blood transfusion. Vegans (yeah, that’s a secular religion) are forced to feed their kids animal protein in Belgium.

    When you impose those limits on the rights of parents on the bodily autonomy of a child, how justified is making an exception for medically unnecessary circumcision? Jews and Muslims should have religious freedom, but shouldn’t Jehova’s witnesses and vegans have that freedom too? If we ban one but not the other, how can that be justified?

    And you could say life preservation is a terminal value, so it’s OK to ban parents from potentially killing their child by denying them blood transfusions and proper nutrients, but then there was Alfie Evans’ case, where the parents weren’t allowed to take a child out of the UK for some life-extending treatment on doctors’ opinions.

    • EchoChaos says:

      My point of view is that parental authority over minor children should be NEAR absolute, especially in religious matters. I am an American Christian, so that’s where my bias comes from, but I would support the right of Jehovah’s Witnesses to determine the medical care of their children, including end of life decisions.

      Vegans I regard as foolish, but as you say, secularly religious, so I would support that as well.

      • AlexanderTheGrand says:

        How long do you feel this should hold? At what age should the child’s expressed concern matter? And what are these dependent on? I’m not antagonizing, I genuinely want to know.

        • EchoChaos says:

          How long do you feel this should hold?

          Age of majority, which is traditionally somewhere between 13 and 18 depending on local custom and law.

          At what age should the child’s expressed concern matter?

          A good parent should always take that into account at least, but legally, not until age of majority.

          And what are these dependent on?

          Local culture. Religious tradition usually puts it at about 13, and I’d find that a reasonable lower bound. American law allows for emancipation at 14, which tracks pretty well there.

          • Age of majority, which is traditionally somewhere between 13 and 18 depending on local custom and law.

            Twelve and a half (plus evidence of puberty) for women, if you go by Rabbinic law.

    • Purplehermann says:

      would it be fair to say we grant parents authority, as long as they are using it in a way that isn’t too bad (objectively) for the children?
      Circumcision isn’t a huge deal from a secular standpoint (or shouldn’t be, a possible change in intensity of sexual enjoyment is not a huge deal imo) , so parents decide.
      Sacrificing the child to moloch, no.
      Starving or torturing the child, no.
      What school, yes.
      If the child can have one candy or two, yes.
      Any medical procedure the medical community condones for the child, done by a qualified proffesional, yes. (Ending life type procedures is a tough topic, this is about normal procedures with the child’s long, healthy, enjoyable etc life in mind as good things during the decision making process).

      • ana53294 says:

        Starving or torturing the child, no.

        And does veganism count as starving a child by denying them animal protein?

        The lines are a lot fuzzier at the edges than it may seem.

    • PedroS says:

      My reading of the judge’s opinion in the Alfie Evans’ case is that the boy was not prevented from having the treatment itself, but that transporting him to the Roman hospital would require the removal of his life-support system and that the risks to his life and well-being were too large compared to the possibility of success. My instincts on that case were pretty much against the court decision but when I read the actual decision I was impressed by the care and compassion shown by the judge and by the complete disconnect between the popular narrative that I had drank and the actual facts of the case.
      PS: I do not claim to have the sole correct interpretation of that poignant drama and I may have misremembered some details. But I am sure that it was not a “simple” case of the state over-riding parental rights due to its “knowing best what is good for the proles”

  34. DeWitt says:

    Two points against any studies about circumcision:

    Circumcised men are not selected randomly. If you studied circumcised men in Europe, where circumcision doesn’t often happen, you’d find circumcised men to eat much less pork than their uncircumcised peers. We don’t assume that this means circumcision makes you allergic to bacon any more than we should assume that the other supposed health benefits of circumcision are caused due to the surgery rather than selection effects.

    Secondly, the medical industry makes money off of circumcision. A lot of it. In the day and age of replication crises, it’s not a crazy thing to note that studies which support literal millions of surgeries a year, at great monetary benefit to their providers, may in fact be motivated reasoning odn their part to see them continue. Of course the people making money off of this are more likely to support it.

    .. And why is money never mentioned, anyhow? Is it assumed circumcision just kind of happens? That the money could be spent on nothing else at all? Are doctors so underworked and bored that their time could be spent on nothing else?

    These concerns may not be warranted. Might very well be, in fact. That they do not seem to have been raised at all suggests to me that the anti side of this AC plainly hasn’t been trying very hard.

    • ana53294 says:

      EchoChaos linked this NYT article. It’s mentioned that:

      For example, the birth of a baby boy may automatically prompt a bill for a circumcision; having day surgery may prompt a check for sedation.

      So you pay the circumcision whether you go through it or not, because insurances can’t be bothered to get items from the bill off, even if you didn’t do the procedure.

      • DeWitt says:

        It’s a cost they’d not get away with slipping through so easily if circumcisions weren’t, in fact, the default.

    • thisheavenlyconjugation says:

      I agree that the anti side seems very weak, but cost is unlikely to be a relevant factor — newborn circumcisions only take 5-10 minutes AFAIK, so the presumably dominant cost of the surgeon’s salary is pretty small.

      • Cliff says:

        Don’t be so sure. In the U.S., doctors regularly bill thousands of dollars for a few minutes of time. This is not an exaggeration.

  35. Etoile says:

    (Edited for clarity)

    I am generally a supporter of circumcision; most male babies I know in my acquaintance and extended family were circumcised. However, I haven’t had to make the decision for a child of my own yet, so I don’t have any skin in the game, so to speak.

    With that said, I think this collaboration omits an important aspect: that of the baby’s potential pain and suffering, potential trauma, and possible consequences of such trauma on future psychological development. These arguments give me the most pause in deciding to circumcise a child if I should have a boy, and I would have been interested to see the research out there on that.

    There’s also a less-convincing argument I’ve seen tossed around about the psychological consequences of boys having a penis different from their fathers, or from their siblings, or from other boys in the school locker room. It’s not convincing to me, but I’ve never been a boy, and it should also have been addressed.

    • Thegnskald says:

      Men’s bodies should belong to them, personally. I don’t think the choice is rightfully yours to make in the first place; weighing the pros and cons is something somebody should do for themselves.

    • DeWitt says:

      I don’t have any skin in the game, so to speak.

      Well that had me giggling, thanks.

    • Randy M says:

      There’s also a less-convincing argument I’ve seen tossed around about the psychological consequences of boys having a penis different from their fathers, or from their siblings, or from other boys in the school locker room. It’s not convincing to me, but I’ve never been a boy, and it should also have been addressed.

      I have never really understood this impulse or concern, or a desire that the boy should look like his old man or whatever.
      Maybe I am unusual in spending literally zero time in my life on penis comparisons.

    • EchoChaos says:

      There’s also a less-convincing argument I’ve seen tossed around about the psychological consequences of boys having a penis different from their fathers, or from their siblings, or from other boys in the school locker room.

      I grew up uncircumcised in the United States in the 80s and 90s and was circumcised as an adult. It was occasionally noticed and commented on, but not often and never nastily. I have no psychological consequences from it.

      Do with this anecdote what you will.

      • ksdale says:

        I second this anecdote, I was the only one in my group of friends growing up that was uncircumcised and it was nothing more than a bit of a novelty for everyone. My father was also circumcised and it never even occurred to me that it might be weird that we were different.

    • hls2003 says:

      I genuinely don’t understand the “infant trauma” position. Do these people not have babies themselves? Babies are traumatized much more by gas and reflux every day than anything they would experience from the circumcision. There is little or no pain during the procedure itself, at least in the medical context (and I strongly doubt in the mohel context, though that’s not my religious background so I don’t have experience). Then you change the cotton for about three days and, if you see any redness or sensitivity, add a little Neosporin (now with topical pain relief) or petroleum jelly. From every visible (and audible) indication of distress – WHICH BABIES ARE NOT SHY ABOUT GIVING – the babies don’t care. They’re bothered vastly more by the imposition of arranging their legs to change the diaper generally than they are by the abrasion down below. It is of virtually no trauma to the baby. I hate to be uncharitable, but anybody really arguing “Unconscious trauma! Emotional scarring!” sounds like either a non-parent of boys, or a hysterical fabulist, or both.

      • NoRandomWalk says:

        As a non-parent, (hopefully) future parent of boy(s), this was reassuring. Thank you.

      • zoozoc says:

        As someone who was present while the circumcision was occurring for my baby boy, I can say that the surgery itself only caused mild discomfort and pain. However, it did bother him that day and night as we noticed he was much fussier and cried more frequently. So it wasn’t nothing, but it also wasn’t bad enough to cause full blown inconsolable crying fits or even major crying.

      • Jacobethan says:

        Totally second this comment: completely matches my own experience as a parent.

        I think this is a point for the pro- side that could’ve been spelled out more clearly. Not only are the nonsubjective utilitarian benefits of circumcision marginally greater if it’s done as an infant, but the degree of subjective suffering is to all appearances vastly less than if the procedure is put off until it can be done consensually.

        In this regard I’m not even sure I’d frame it as “infant” circumcision, since I could imagine the implications for mental suffering being totally different at, say, 4 months. It’s really that newborn psychology is just incredibly unlike anything we have direct experience of, in terms of our usual intuitions about relative sources of distress.

    • Space Ghost says:

      I was born in the US in the early 80s and not circumcised. In my experience comparisons are not an issue – I couldn’t tell you whether or not my father or brother are circumcised, and no one in the locker room was getting fully naked. There was some mild discomfort during the teenage years around being “different”, in the context of “what will girls think?”, but in my experience most women *can’t even tell* in the heat of the moment, or don’t actually care – flaccid penises are not generally something most women are interested in. Furthermore circumcision is less common now, so that should be even less of an issue going forward (although it will depend on your subculture – it’s probably more of an issue if you’re Jewish or Muslim, for example)

      On the subject of trauma – the standard of care these days is to use anesthesia (wasn’t always the case, shockingly enough, and perhaps there are older providers out there who still operate this way). I witnessed my own sons’ circumcisions, and anecdotally they did not seem affected by it at all. The doctor used a local anesthetic cream as well as an injection, and sugar water on a pacifier.

  36. caryatis says:

    The point about there being no evidence that homosexual transmission of HIV being reduced by circumcision is the most important one here. As a parent, you can’t tell at birth whether your child will be gay, but you can determine whether he is non-black and likely to live in the US. If so, heterosexual HIV transmission is vanishingly rare, and the case for circumcision is much weaker.

  37. vectorious says:

    I would have preferred absolute rather than relative risks – from what I can tell the Cancer risk is remote and so a cut in it is not a very significant point in considerations – I think a lot of the risks and benefits considered here could be small absolute items which would diminish that side of the argument.

    I also note that a quick google suggested that penile cancer rates are 1 in 100,000 in the US and 1 in 250,000 in Australia – and I would have thought that the higher proportion of circumcised men in the US would invert this stat – so there is some confounder here.

  38. Psychoparmacologist says:

    Here are a few comments from a German perspective.

    I would have liked to see a better definition of what the authors are talking about. Is it state of the art circumcision in a hospital? If it is about religiously motivated circumcision, there is an important argument to be made, about the lack of pain management. Because yes, infants can feel pain!

    To get a different opinion you can read the statement of the German Society of Pediatrics. They argue strongly against circumcision, based on the rights of the baby. In addition the prevalence of the diseases mentioned by the text is quite low. (I’m sure Google translate can help you out if you don’t speak German)

    And I find the part on urinary tract infection misleading. Most urinary tract infections, even in infants, can easily be treated with antibiotics. I would like to see the number to treat to prevent a UTI that has long term consequences. The sources I trust on this are in German. If there’s a pediatrician reading this, please do comment.

    • They argue strongly against circumcision, based on the rights of the baby.

      My German isn’t good enough to analyze their arguments, but that strikes me as analogous to a philosophy professor arguing against circumcision based on its medical consequences.

      Doctors have no expertise in the subject of rights, so there is no reason to take their conclusions seriously, although they, like anyone else, might have interesting arguments to offer.

      • Psychoparmacologist says:

        You make an interesting point. I would have two seperate responses to that.

        In Germany pediatricians see them selves as holistic in the none esotheric sense. Everything that has to do with children is their domain. This can certainly be seen as bold aspiration, but they certainly have a different role than the doctor of an adult. After all they’re supposed to have an eye on the mental not just somatic development. In addition, they see themselves as a defendor of children in general, because they think they have the expertise and don’t want history to repeat itself (see any history book on the 20th century). And in this role they wrote this article. I write that not to defend their statement, but as context.

        I do however would want to whole-heartedly argue that we should take them seriously and not only because they are experts on children. They argue from a basic human right on physical integrity. This is too basic a topic to our society to only let people with the right degree speak up on it. I am certain, you do not intend to say that, but this argument could be used to stiffle public discourse to the extreme. I certainly could not comment on this adverse collaboration and expect to be taken seriously. I am neither a philosopher nor a medical doctor.

      • devonian22 says:

        The UK’s National Health Service no longer pays for routine neonatal circumcision – their medical opinion is that the costs don’t outweigh the benefits. No recourse to rights needed.

  39. TenthKrige says:

    I would have emphasised the potential harm of promoting a norm of performing an elective surgery on children for minor health benefits or, more realistically in the US, under peer pressure.

  40. zoozoc says:

    Since no one has mentioned it, I would like to add one more piece of evidence for the pro-circumcision side. Studies have found that circumcision helps prevent STI transmission and cervical cancer to their woman partner. Here is a link to an review of the relevant studies.
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5728090/

    • hls2003 says:

      Thanks for mentioning that, I had seen that study when considering the matter with my wife. Given the cervical cancer linkage, I think it would be interesting to compare the overlap or contrast of attitudes between those who oppose optional circumcision and those who oppose the optional HPV vaccine.

      • zoozoc says:

        I didn’t realize that cervical cancer was what the HPV vaccine prevented (I am a man and it didn’t exist when I was growing up). I am not sure if the studies compare HPV vaccine to circumcision or a combination of the two vs. just one. I suppose this pro-circumcision evidence ends up being much more similar to the HIV-prevention evidence, in that there is an alternative that exists and (at least with condoms) is better than circumcision and the fear that those who are circumcised will forgo the alternative.

      • Thegnskald says:

        I strongly oppose infant circumcision, and have a complex position on vaccinations.

        Approximately, I don’t think parents have a right to give their children vaccinations under normal circumstances, but I think the government does and should, given its interest in disease control, which I think overrules bodily autonomy, weighing the interests against each other.

        • hls2003 says:

          Interesting. So the state gets to decide, but not the parent. I would guess that’s an unusual position, but I don’t have any polls to compare. Also, HPV is not an environmentally communicable disease like pertussis or measles, and thus many parents opposed it being made mandatory (and I think it usually isn’t in most states). The notable comparison, then, would be parents voluntarily choosing it for their children to reduce their HPV risk despite the state declining to make it mandatory. It sounds like your response would be that the parent ought not do so.

          • Thegnskald says:

            I think the state should make it mandatory, but absent that, yeah, the child should have a say in the matter whenever possible; absent that, I’m fine with parents giving their children the choice, but the choice should be respected.

          • NoRandomWalk says:

            @Thegnskald can you respond to the claim that children are dumb and unable to plan ahead/judge risks and benefits/care about the future, and that parents generally care about their children’s wellbeing and on balance letting them force their kids to do a fairly broad set of things is appropriate.

          • Thegnskald says:

            As a child, I was smarter and more forward thinking than the parent who made most of the decisions, so the unusual circumstances of my childhood color my perspective of the interactions between parents and children.

            That said, yes, parents are generally somewhat better at those things than children, and where the decision cannot be deferred, should make the call.

            The “cannot be deferred” part is critically important, and where the “normal circumstances” part comes in.

            I think the appropriate way to look at a parent is a caretaker, not an owner, of a child. We could analogize to a doctor who has an unconscious patient, where unconscious is doing the work of “undeveloped”. You don’t want a doctor performing circumcisions on unconscious men just because it would be preferable to them being conscious when it happens. You don’t want your caretaker nailing boards to your house.

            But if your unconscious patient has an infection for which circumcision is the best available treatment, and it must for whatever reason (coma?) be treated before the patient will wake up – or if a hurricane is about to arrive at the house being caretaken, circumstances permit, and perhaps require, action that wouldn’t otherwise be permissible.

          • cuke says:

            FWIW, Thegnskald, your view of parenting sounds the same in this regard as mine and your metaphor about caretaking works for me.

        • NoRandomWalk says:

          @RC Cola
          [Edit: who deleted his comment asking for clarification?]
          His position makes sense to me (from a certain perspective).
          You are vaccinated primarily for the benefit of your neighbors, who have a ‘right’ to not get infected.
          Forcing vaccinations on others can be considered a form of self defense.

          Parents usually do socially-objected stuff to kids because they have a moral perspective, that differs from society, which is a different category.

          Everyone (including me) wants to be able to brainwash their kids more than we want to brainwash (read: ‘socialize,’ or ‘raise into a good person’ for competing definitions of good and desired social norms) other people’s kids, so we (as a matter of political economy) result in norms of various strength where parents can do what they want to their kids within certain boundaries.

          He seems to accept the self defense argument, and rejects the politically negotiated norm as being undesirable because kids might have their own moral views (different from both society, their parents) that they just don’t yet have the political power to express.

          • RC-cola-and-a-moon-pie says:

            Sorry, I did delete it because it was imprecise. I tried to clarify a bit here and then deleted it again. Too hard to be both accurate and concise. But thank you!

        • Evan Þ says:

          That’s a curious position. Don’t parents also have an interest in keeping their child healthy? Or, do you think that interest is so low in most modern circumstances that bodily autonomy overrides it – and if so, do you expect that’d change during an epidemic?

          • Thegnskald says:

            That is a reasonable summation of my positions, yeah.

            I’d hesitate a bit about the parental interest in health, not because it is wrong exactly, but because there’s nuance I have trouble expressing there.

        • What I judge harshly is the culture, which treats men’s bodies as belonging to anyone but themselves.

          Approximately, I don’t think parents have a right to give their children vaccinations under normal circumstances, but I think the government does and should

          So men’s bodies belong to themselves — and the government.

          I think we have better reasons to expect a parent to make decisions in the interest of his child than we do to expect a government to make them in the interest of the people it governs.

          Do you disagree?

          • Thegnskald says:

            There’s some nuance to my agreement and disagreement.

            Parents will make a better decision for the child than the government. The child will make a better decision still, so if any decision can be deferred for the child to make, it should be.

            The government will make the decision that is best for society, which is where I think questions of vaccinations belong.

          • NoRandomWalk says:

            “people it governs” isn’t one category, in this discussion.

            He’s saying that the government cares more about adults other than the parents, than the parents do.

            Which is why we have government. (Which is why I am persuaded that government has the power to mandate vaccines, especially in cases of epidemic and lack of naturally occurring herd immunity)

            I do think your libertarian framework is more relevant in the topic at hand though.

          • Nick says:

            What does better mean here? There are lots of bad decisions I would have made as a kid. The decision whether to brush my teeth or not could have been deferred to me, but it’s a good thing it wasn’t.

          • Parents will make a better decision for the child than the government. The child will make a better decision still, so if any decision can be deferred for the child to make, it should be.

            I agree, provided that “can be” means “can be at little cost.” But the claim we have seen is that infant circumcision is much less of a medical problem than adult circumcision.

            The government will make the decision that is best for society, which is where I think questions of vaccinations belong.

            Why do you believe that? Is it consistent with your observation of decisions governments actually make?

            My standard counterexample is the case of tariffs. The economic analysis of foreign trade was worked out by Ricardo about two hundred years ago, and is still the analysis accepted by economists—perhaps one of the few questions on which I and Krugman would agree. During those two centuries, only two polities I know of—Britain in the 19th century and Hong Kong in the 20th — followed the policies implied by that analysis. Both were, economically speaking, spectacular successes.

            Public choice theory provides a simple explanation of why the trade policy that is bad for the population is nonetheless politically profitable, and observed policies fit that theory. They do not fit the various special cases in which accepted trade theory provides exceptions to the general rule favoring free trade.

            If you don’t like that example, think about other policies that you regard as spectacularly unwise. If there are none, you are unusual person.

            Especially here.

          • Thegnskald says:

            Mandatory vaccinations are pretty much my go to example.of a wise decision, which is somewhat circular here.

            As for adult circumcisions, I’ve stated this in two other places, but I strongly doubt the evidence suggesting they have more complications, not least because the studies I have seen stopped before puberty, when many of the complications would arise, but also because some complications will be judged against a baseline of normal which an infant just doesn’t have.

            Personal, anecdotal evidence also flows into this, because I’ve dated a number of men whose circumcision related complications didn’t show up until puberty.

            I think it is meaningful that a lot of the opposition to circumcision comes from gay men, because for cultural reasons relating to sexuality, I think they’d be the most likely to notice problems.

          • @Thegnskald:

            I wasn’t reacting to your specific point about vaccination, but to the more general

            The government will make the decision that is best for society,

            You may well be correct that in the case of vaccination the government makes the right decision.

          • Thegnskald says:

            The function of the CDC is part of what started moving me away from libertarianism as my political philosophy; quite simply, I lost an argument. I had to concede that the government has a legitimate interest in public health, at least as far as infectious diseases go.

            I’m uncertain where I am politically now. Disaffected leftist, maybe. Basically I think the Democrats are elitist parasites on leftist philosophy pushing crony capitalism while calling it anything else, and the Republicans are a confused morass of whoever the left has most recently pissed off.

            My political goals might be summarized as “eliminate the stock market”, largely because I think the financial industry is basically parasitic. (Financial industry pricing information is tautological, in a sense; it wouldn’t have value without the industry.). I’d rather corporations either be privately held, or own themselves.

            I have no issue with the salaries CEOs make, but I’d rather their job have more to do with managing their company than managing shareholders.

            Effectively, my personal political goal is to make capital own itself. I don’t expect the Marxist revolution, I just expect less dead weight in the economy.

            ETA:

            Not that I want to ban public corporations. I just want to make them obsolete. Start with one self-owning corporation that buys other corporations and converts them into self-owning corporations. If it is successful, the infectious design will take over. It is isn’t successful, it goes away.

            I don’t want to discourage people from starting new businesses, after all, and I’d like to reward it. If the infectious design buys them out, that from their perspective shouldn’t be worse than anyone else buying them out.

          • Start with one self-owning corporation that buys other corporations and converts them into self-owning corporations.

            What is a “self-owing corporation”? Something like the Catholic church”?

            Who controls it, what are the incentives, who if anyone is the residual claimant?

          • Aapje says:

            I assume that it means that some or all the workers own the company.

          • Thegnskald says:

            The corporation owns all of its own stock; no external agent has control over it, or receives dividends from it.

            The workers have voting rights over the administration, which would behave generally like ordinary administration.

            What would be profits are split between the workers and investment in buying new companies and converting them, with a kind of profit-sharing mechanism between companies.

            Workers accumulate claims of future profits over time. Administrative personnel accumulate more, possibly getting their primary pay in that form, with the goal of incentivizing long-term planning.

            Some poison pill mechanics to dismantle corporations who lose part of their ownership of themselves, like if a lawsuit occurred.

            A mechanism to dismantle unprofitable corporations, using profit sharing as a mechanism to continue to pay out to employees on the basis of their claim of future profits (which would otherwise go towards closing the gap between earnings and expenses). The goal is to incentivize employees to want their company to close shop.

          • @Thegnskald:

            I would describe that as a worker’s co-op. They exist, but they seem to be very uncommon relative to the joint stock company model, in places where the latter is legal.

            One problem is that the workers have an incentive to avoid hiring more workers, since each new worker dilutes the ownership share of existing workers. Another, if the firm is reasonably large, is that monitoring the behavior of the managers becomes a serious public good problem for the worker/owners. You don’t have any equivalent of the takeover bid mechanism for that purpose.

            A third problem is that the firm cannot expand unless it is currently profitable and workers are willing to postpone their own consumption. A solution to that is debt, but not all lenders will be willing to lend with no control over the firm’s behavior, since the interest of workers is not obviously consistent with that of the creditors.

            As you may know, Yugoslavia had a system based on workers’ co-ops, and I believe there is a literature on it, although not one I am very familiar with.

  41. Thegnskald says:

    Also, a note on comparing complication rates between infant and adult circumcision:

    Among those who are cognizant of, and able to complain about, complications, complications are higher. When you notice this, the disparity in rates stops looking quite like “Infant circumcisions are clearly safer” and more like “We have no idea what percent of people simply lack a baseline by which to compare their experiences pre and post circumcision, and the true rate is probably hidden by the fact that the problems just feel like “normal” to many affected people”

    • Aapje says:

      Very good point.

      Also, when the problems occur during puberty, rather than directly after circumcision, the two may not be linked, even if they are. This is the yang to the yin where coincidental occurrences are seen as causally related (like vaccines causing autism).

      • Thegnskald says:

        Also also, complications for uncircumcised men may be solved by circumcision, which if you think in terms of interventions rather than complications, effectively means we are counting interventions in the uncircumcised case we aren’t counting in the circumcised case.

        Assuming the 2% of later circumcisions are almost all medical, the 2.8% of uncircumcised adult complications should be reduced to somewhere closer to .8%, meaning complications requiring a non-circumcision intervention are three times higher for circumcised men.

  42. Icedcoffee says:

    I’m a bit confused about some of the mechanics of this. (It might be I just fundamentally misunderstood the purpose of the adversarial collaborations project.)

    1) Neither side states up front what findings would lead them to change their position. If neither side is willing to change their mind, then what is the point of looking at the evidence?

    2) Shouldn’t there be a discussion of presumptions, burdens, and sufficiency prior to diving into the evidence? Who is trying to persuade whom? How much evidence is required to make their case? (I would assume that we care not just about “if” there is a potential benefit, but “how much” benefit there is.)

    • Randy M says:

      As far as I understand it (it’s Scott’s baby, he can correct me), and adversarial collaboration is not a debate. It isn’t an attempt to change anyone’s mind. It is an attempt to lay out the evidence with that both sides can agree on, and whatever disputed evidence along with the required caveats. Along with, perhaps, arguments about why certain evidence is relevant or weightier and such.

      It’s an attempt to come to an agreement on what is currently known, not an attempt to put the issue to rest.

  43. J Mann says:

    Very nice article, thanks! I didn’t really know much about the topic, and now I feel I do.

    I would have loved two more things:

    1) Some attempt to quantify the absolute impact – i.e., how many lives would be saved/lost if the entire US male population were circumcised at birth vs uncircumcised for life?

    2) A section on the author’s initial opinions and whether they changed during the process.

  44. DinoNerd says:

    I was disappointed somehow with this collaboration, and reading other people’s comments have helped me put my finger on some of it.

    1) All the risks/benefits involve seem low. In such a case, an argument about reducing (or increasing) relative risks looks very different when expressed in terms of absolute risks.

    2) The discussion seems more in line with a question of “should baby boys be circumcised”, rather than “is it ethical to circumcise them”.

    3) I happen to know for certain that not all the circumcision risks are covered. A friend of mine was uncircumcized – in a country where circumcision is routine – because his mother discovered she carried the gene for hemophilia very much the hard way – his elder brother died as an infant of hemophilia + circumcision. (My friend was their only non-hemophiliac son; a younger brother was also hemophiliac, and died as a very young adult after receiving a tainted transfusion.) The risk of hemophilia is pretty low, and in developed countries there are now prophylactic measures taken just in case – but the absence of mention of this risk leaves me asking what other risks are missing.

    • zoozoc says:

      While this collaboration didn’t try and do some kind of utilitarian math, it did provide most of the statistics that are required to attempt such math. For #3, I believe any deaths would fall under the 0.2% for major interventions, but maybe I am wrong. I couldn’t find any easy numbers when googling.

  45. JohnBuridan says:

    Good article. I can see how some people found the title misleading, but I find it totally uncharitable that some commenters question your integrity and claim that piece is dishonest work. If Scott thought it was, he would not have published it on his blog.

    Don’t let the criticism get too far under your foreskin. It takes resilience to publish something for public scrutiny, and you’ve done a great job stimulating discussion! +10000 nerve endings!

    • Thegnskald says:

      I think the responses are less about dishonesty, and more just coming away with the impression that the article was mostly written by the pro side, with limited input from the anti side, perhaps because the anti side just didn’t contribute much effort.

      I, for example, would have insisted the bit about infant brain plasticity be struck from the article, because it doesn’t belong; it is a flag that one participant was driving most of the collaboration.

    • hls2003 says:

      I agree it was a decent write-up of most of the basic medical tradeoffs. But, despite being somewhat pro-circumcision myself, I see where commenters are complaining, too, because the literature review seems like only one part of the equation. It is necessary and proper to assess how dangerous the procedure is, how much (if any) harm it causes, and what benefits it provides. Once you have determined that the procedure is overall positive-to-neutral in physical effects, though, I can still see a principled argument about bodily autonomy being made. I might disagree with that argument, but I think it merited more discussion when the question under consideration was whether it is ethical. It’s fair to start by debunking the more over-the-top factual accusations of either side, but it didn’t continue to address the normative claims the nay side would offer even if the procedure is not harmful.

  46. Two McMillion says:

    These men were randomized to be circumcised or not at the start of the studies for primary HIV prevention.

    I would have loved to hear the conversation which followed, “Congratulations, you’ve been randomly selected to be circumcised.”

  47. EGI says:

    Huh, I’m extremely surprised about the “no clearly lowered sexual sensitivity” part. I’ve been circumcised for medical reasons at 5 years of age and have slowly but clearly decreasing sexual sensitivity over my whole live to the point that at the moment (age 35) orgasm from PIV intercourse is difficult and from oral next to impossible (masturbation still works fine but also became more difficult). Also in the first decade or so after the circumcision (before developing a keratinized surface) my glans often developed sore or raw spots from friction on my clothes.

    I always chalked this up to my glans being exposed all the time and developing a dry, skin like surface instead of the typical wet mucosal one.

    Of course this might be an unrelated quirk of my physiology, n=1 and all. So I’m very interested if other people have similar experiences with / without circumcision.

    • EchoChaos says:

      I had the opposite experience. I was circumcised for religious reasons at 20.

      I am 37 now and have seen no decrease at all in either libido or sensation.

  48. thisheavenlyconjugation says:

    Has anyone else who was unimpressed by the detail of the discussion about sexual satisfaction done a more thorough review? This page seems like a reasonable starting point.

  49. Space Ghost says:

    Question for people who did or would choose to circumcise their sons for religious or cultural reasons – if the health benefits were precisely the opposite (e.g. being uncircumcised decreased the rate of HIV transmission by 50%, decreased the rate of penile cancer by 90%, etc) would you still do it?

    • aristides says:

      If both were reversed conclusively, I would switch sides to not circumcising my child. To be honest, penile cancer is doing the work, US heterosexual HIV is so low, and non deadly to be a concern. I would still not switch to the point of legally banning the practice though, I just wouldn’t have my sons circumcised.

      • thisheavenlyconjugation says:

        Penile cancer certainly shouldn’t be doing the work either since it’s also incredibly rare (and the benefits of circumcision seem somewhat dubious based on comments here claiming that it is less frequent in countries where circumcision is much less popular).

    • EchoChaos says:

      I would still circumcise.

  50. Chad_Nine says:

    Nothing about the psychological impact on the infant? That’s a rather large omission.

    • Jacobethan says:

      Is there anything that leads you to suspect the impact would be more than trivial?

      I have no idea if it’s ever been studied, but speaking purely from experience, if you see an infant circumcision you’ll quickly understand why any associated suffering might not seem worth taking time to try to quantify. It’s impossible to know exactly what’s going on inside a newborn’s head, but the behavioral presentation suggests an affective response that’s negligible to the point of almost not noticing.

      I suppose in principle it’s still possible that there’s some important effect we’re just not picking up on. But from an observational standpoint it just seems like a really arbitrary and random thing to seize upon (out of all the daily stuff that babies really do seem profoundly bothered by) and say, “Hey, what if that one thing that made him cry for like three seconds was secretly really traumatic?”

  51. kai.teorn says:

    > No available studies actually measure sensitivity to sexual stimulation

    And that sounds like the root of a whole unexplored tree of issues. If c. reduces sensitivity, it may mean that men with c. must work harder to achieve the same level of satisfaction and release. This may mean longer and more physically demanding sex sessions, which may make lovemaking less frequent. This may also lead to a decreased satisfaction in their partners who may, on average, prefer a more cuddly and intimate, rather than pounding and workmanlike, kind of sex. Finally, reduced sensitivity may have even larger implications later in life when erection becomes a problem for many – for example older men without c. may still be able to achieve orgasm, due to their larger sensitivity, but for those with c., loss of erection may more often mean the end of active sex life.

  52. Rory says:

    I got to the section of this article on HIV, and I stopped there. Any discussion that references the African HIV circumcision study as authoritative is clearly unscientific propaganda. That study failed to normalize the measurement period for sexual activity, and so they strangely forgot that circumcised adult men would be unable or unwilling to engage in sex for weeks or even months following a circumcision. So of course men not engaging in sex are less likely to contract HIV than men who are engaging in sex. If this is the level of discourse in the article, it’s no wonder that so many of the comments are baffled and confused by what appears to be a jumbled and unbalanced mess of opinion and appeal to authority.

    I would bet this poorly written article also doesn’t mention that circumcised men have three times the amount of orgasm difficulties compared to men whose foreskin is left intact, and that the primary motivation behind circumcision has always been to prevent young boys from masturbating. Just look up the name John Kellog if you don’t believe the true purpose behind circumcision.

    • Nornagest says:

      “Unscientific propaganda” is a bit strong, but that bit of the AC didn’t pass the sniff test to me either. I don’t have a dog in this fight, and I’m not going to bother reading papers on it, but the results as cited don’t make intuitive sense or provide any plausible explanations for their results.

      That being said, the fact that John Kellogg thought something would help prevent masturbation doesn’t establish that he was right to do so. John Kellogg had a lot of ideas along those lines.

    • and that the primary motivation behind circumcision has always been to prevent young boys from masturbating

      Always? In Judaea more than two thousand years ago? In Arabia more than a thousand years ago? Your evidence?

      This is the sort of comment that makes me stop taking what someone posts seriously.

    • blumenko says:

      The article explicitly rejects the study you quote, due to circumcised men in Denmark generally having a preexisting genital issue.

  53. Otzi Ozbjorn says:

    I’m not circumcised, and I’m grateful that I’m intact.
    I don’t know what motivated my parents to not have it done; cost, possibly.
    I find it appalling that society considers it a decision to be made by anyone other than the owner of the penis.

    • Don_Flamingo says:

      I don’t find that appaling at all, but quite natural.
      The owner of the penis, once capable of making such a life decision cannot retroactively make the decision to have been circumcised as a baby.
      By then, that would have already been decided one way or another.
      Since there is specifically a case for doing it as early as possible, a decision must be made on that.
      It is not avoidable.
      And that decision must be made for the owner, since it can’t be made by the owner.

      • kipling_sapling says:

        I don’t think the decision to wear cloth or disposable diapers should be made until the child is old enough to decide for themselves.

      • Otzi Ozbjorn says:

        The owner of the penis, once capable of making such a life decision, cannot retroactively make the decision to have NOT been circumcised as a baby.

  54. viVI_IViv says:

    Overall, the rate of minor complications (bleeding, bruising) is ~1.5% worldwide and the rate of major complications (scar, severe infection, meatal stenosis, or need for additional surgery) is <0.2%. In comparison, the risk of complications in children past infancy and adults is approximately 6% with trained practitioners – significantly higher than for infant circumcision. Indeed, the majority of cases of the most severe complication (penectomy) related to circumcision appear to occur in people who were not circumcised as infants. This would include both adults with penile cancer as well as children undergoing phimosis surgery (as in the infamous case of David Reimer).

    There seems to be a counfounder here: people who get circumcised past infancy usually do so because of a diagoned medical condition, while infants who get circumcised are usually healthy. It could be the case that most medical complications of post-infancy circumcision are caused or exacerbated by the underlying condition that motivated the procedure in the first place.

  55. StevieT says:

    One question that is glaring from its absence here:

    Are there any other circumstances where it would be considered medically ethical to perform elective surgery on an infant for some purported later health benefit?

    Would it, for example, be ethical to remove female breast tissue at birth to protect against breast cancer?

    If the answer to these questions is “no” (and I strongly suspect that it is), why is circumcision such a special case?

    • Don_Flamingo says:

      All surgery is “elective”. As far as I’m aware the parents can always refuse what is told to them.

      But cosmetic surgery comes to mind. Saving a child from possible bullying comes to mind.
      I’ve also heard it said that some Americans have their boys circumcised so that they don’t feel different from the other boys in the shower.

      Experimental treatment with low chance of success or a high risk/high reward-treatment, perhaps.
      [either the kid dies or he’ll walk-kinda stuff, though I’m not sure if such a situation comes up often]

      Some of the people affflicted by one of the intersex-variations are like that. Where the parents have to pick “boy or girl” or no treatment (and from what I’ve once heard, girl is more commonly picked, because it’s “easier to dig a pit, than to build a tower”).

    • keaswaran says:

      Vaccination is widely accepted. It’s not “surgery”, but it is an elective and painful bodily procedure performed only for later potential benefits.

  56. meh says:

    I think this post did a good job of swaying people in the middle. Talking about bigger picture ethical and philosophical questions may have made better theater for those with an extreme position, but they were not going to be persuaded anyway.

  57. Ceinti says:

    This essay seems extremely slanted to me, and I can’t help but suspect that the anti-person either didn’t exist, wasn’t involved, or didn’t actually care very much about the topic and was very easily converted to the pro- side early on in the process. It’s just not passing the ideological turing test for me, as it honestly seems to me as if this could have been written with no input from an anti- person and it would have looked much the same. I don’t say this to be mean or anything like that, just pointing out that if the intention was to write a piece that could be described as balanced, this will not pass muster for many people who might have expected their concerns to have been taken into account.

    For a start, there’s no discussion of what the changes in risks might actually mean in terms of actual impact. The base rates matter, and the potential outcomes are different in magnitude. As it stands I couldn’t help but feel at many points like I was reading the famous Bayes’ Theorem explanation about breast cancer, without the payoff at the end where it shows you how misguided your intuitions might be if you didn’t bother multiplying through the numbers. This is a very surprising mistake to come from the LW-adjacent readership.

    For example, if 1.5% of 100% of the population get complications from neonatal circumcision vs. only 6% of the ~2% of people who eventually need circumcision as a non-infant get complications, then not circumcising results in 1/8th of the amount of complications in the population.

    Similarly, why was there no gwern style analysis of the costs in terms of time and resources of having to do things like train medical professionals to become good at the procedure, or the time and resources needed to actually perform the procedures? Medical professionals’ time is scarce and they’re spread too thin already in terms of the expertise you would want them to have across their profession and the time in which they’re expected to gather it. The opportunity costs involved to me seem enormous, especially in comparison to the meagre benefits, and to not see any discussion of it is a glaring omission.

    Examples like this could be made throughout the piece. Cashing out the potential effects into units that could have been aggregated so that a comparison could be made, whether time, money, QALY, utilons, whatever, might have been a good idea, but as it stands this reads as incredibly one-sided, where the kinds of concerns that people who are anti-circumcision have aren’t given a voice.

    In general I’m very disappointed by this essay, and all the more so because this is a topic where people’s opinions actually have effects in the real world, because parents make this decision for their kids.

  58. CompartmentalizedIdentity says:

    I hate to invoke heteronormativity, but this comment section is possibly the most heteronormative discussion of circumcision I have ever voluntarily read through. I feel somewhat worried reading commentary by (implied to be heterosexual) fathers, soon to be fathers, or potential fathers on this topic invoking fears of HIV.
    Do these same fathers have strong preemptive stances about making sure that their teenage sons are on prep if they so much as suspect that they might be gay or bisexual? Are any other practices for controlling / preventing the transmission of STIs of greater importance to the heterosexual male commenters here commensurate to their greater improvement of life outcomes than circumcision?

    I don’t think that it’s harmful to hold religious values / observances as extremely personally important, but the absence of consideration for the sexual value and significance of male sexual organs in the ACC post and conversation here seem to suggest a powerful taboo against speaking of male sex and sexuality.
    Sex is an important part of human life and related to social bonding, emotional health, and one of the most fundamental sources of human pleasure, and discounting the effects of cosmetic religious ritual/medical procedures on the human experience of sex is somewhat absurd.
    Sex is important even to the lives of the married, monogamous, religious, heterosexual male, and even those men should be encouraged to consider very seriously whether potential harms to the lives of their sons is worthwhile. (Especially if a harm-reduction replacement ritual observance could be devised, possibly a token nicking of the prepuce or cutting of only the frenular band, to be comparable with less invasive type I FGM?)

    • Don_Flamingo says:

      What comment section have you been reading?
      I just ctrl+f-ed for HIV.
      I only saw dismissals of the potentially reduced HIV-risk being irrelevant to their situation and some doubt about the African statistics that show this effect being reputable.

      And what does “invoke heteronormativity” mean and why is it such a hateful thing to you? I haven’t heard that phrase before. Sounds very alien to my German, unreligious, hetero, uncircumcised ears. [well, my ears as a matter of fact aren’t circumcised either, but you know what I mean]

      • CompartmentalizedIdentity says:

        “Invoking heteronormativity” would mean to deploy ideologically aligned language that could potentially halt conversations or be seen as a crude way to force people out of a conversation because of their sexuality. Under normal circumstances I would hate to seem to form an argument based on the idea that there is some ineffable quality of being gay that would elevate my opinion over other people’s, even on issues of sex and sexuality.

        In the comment section I was reading, I saw a comparatively dense string of conversations (which seem to have already ended? I’m not entirely familiar with the commenting etiquette on-site) which interpreted the ACC to support the idea of nonspecific but clear health benefits. Since HPV is already vaccinated-for and penile cancer is extremely uncommon, it appeared that the center of the appeal to health meant reduction of risk for contracting HIV in adult heterosexual males.
        As my experience with circumcised penises (n>5) showed 1 in 1 rate of what appeared to be diminishment of sexual experience / anorgasmia in my male sexual partners, the entire conversation of comment-section-plus-ACC-post suggested either an unfair devaluation of male sexuality, or a void in available research literature preventing more productive questions from being asked.

        Apologies if my comment might have come off as inflammatory or insensitive in the norms of this subculture.

        • Aapje says:

          Apologies if my comment might have come off as inflammatory or insensitive in the norms of this subculture.

          More baffling than any of those.

          You seem to be interpreting the article and various comments as being dismissive of a male loss of pleasure (where the article and many of these comments actually seem to reject that pleasure is lost), which you in turn interpret as anti-male, which you then interpret as anti-gay.

          I don’t understand how you draw these conclusions.

          I’ve seen people apparently reason like this:
          – I’m X (in this case, X = gay)
          – I’m offended by Y and/or it fails to include my perspective
          – Y is anti-X (in this case, anti-gay)

          This is my best guess of how you reason, but it is a flawed kind of reasoning.

        • cuke says:

          I found your comment helpful.

    • Clutzy says:

      If my son, which I do not have, I’d certainly encourage him to talk to a doctor about PREP. Sex is dangerous. Homosexual sex is statistically much more. When I was young I thought heterosexual sex was as dangerous as homosexual is in fact, and it scared me severely.

  59. TheTrueScotsman says:

    Like many others here I was very disappointed by the anti-circumcision side.

    1) I’m confused on why there was just one short paragraph on ethics. The ethics of this go beyond the personal autonomy of making your own medical decisions. It’s not just that men are upset because they didn’t get to decide, many men feel violated by circumcision because it involves modification of a body part containing a lot of psychosexual significance. It’s hard to quantify how many men regret being circumcised, but this study (in the notes section) had a sample where 13.6% of circumcised men reported that they wish that they had not been circumcised. A YouGov poll found 10% of circumcised men surveyed wish they had not been. I doubt 10+% of people regret getting vaccinated as infants or getting braces as children because neither of these involve the modification of a body part in a very intimate and sensitive region of the body. Braces and vaccines don’t compromise sexual or masturbatory function, which we all care a lot about.

    2)The collaborators concluded that the “evidence does not support any change in sexual pleasure” other than maybe masturbation. However, the systematic review they cited on there being no difference in sensitivity in the glans is biased at best, if not completely rigged. Krieger and Morris have a very long history of rigging systematic reviews in favor of circumcision See: here and also this. The African surveys did not ask about masturbation. There is not a single study of sensitivity in the circumcised vs uncircumcised penis in the erect state which surely is critical to ascertaining if there are any differences in sexual functioning. Thus it is my belief that the evidence on the sexual effects of circumcision is far murkier than the collaborators claim. Given the lack of evidence so far, I believe the default assumption should be that circumcision negatively impacts sensitivity given that the foreskin has nerve endings and its removal therefore must entail a decrease in overall sensitivity. This is the argument set forth by a bioethcist here.

    3) I am also disappointed that the anti-circumcision side did not re-frame some of the medical benefits in terms of absolute risks. You’re more likely to be struck by lightning than to get penile cancer in the United States, regardless of circumcision status. The canadian pediatric society estimates that it would take one hundred (100!) circumcisions to prevent just one UTI and these are easily treated with antibiotics. The HIV RCTs are the most compelling reason and even here, the absolute risk reduction is less than 2% and surely would be less than a percent in developed countries with lower HIV base rates and higher rates of HIV transmission through injecting drug use. Furthermore, less invasive preventive measures against STDs exist (condoms!).

    In conclusion, I don’t think the anti side was adequately represented.

    • Don_Flamingo says:

      3)
      The UTI-stats surprise me. I’m uncircumcised and I occasionally get pain in the urethra. It’s not fun.
      When I first learnt the concept of “UTI” I thought this what that was. Might have had that happen a dozen times or more. But since it usually goes away within a day or so, it’s not something to go to the doctor for or take antibiotics. I remember reading that one advantage in the male urinary system is that UTIs go away a lot faster. So that would imply that it’s more like a cold.

      So I either suspect that most UTIs are a frequent “subclinical” annoyance and that if circumcision saves you say…. half of them, it’s completely irrelevant how many antibiotics-treatment would be saved.

      Or I just have no fucking clue what an UTI is.

      • TheTrueScotsman says:

        It is very uncommon for males to get UTIs past year 1, regardless of circumcision status. The benefit of circumcision against UTIs is just in year 1 of life and even then you’d have to circumcise 100+ babies to prevent just one UTI.

      • ana53294 says:

        As a female who has had a UTI, you would know if you had a UTI. It goes well beyond pain in the urethra (visiting the bathroom as soon as you feel discomfort could reduce it, maybe?).

        Serious UTIs lower blood pressure, because kidneys are affected. I almost fell down when I woke up, and could barely stand. It’s not something you aren’t sure of.

  60. sentientbeings says:

    I probably should have posted this a day ago but hopefully enough people are still reading the comments. I saw several instances of people claiming, seemingly with high confidence, that masturbation requires lube for circumcised individuals.

    That claim is very much false (and is oh-so-easily-verified for a great many people), which makes me wonder, where did it come from? For those that believe that (or even just heard it), how did that come about?

    And as a second question, if you believed that, are you now willing to re-evaluate your belief based on the testimony of people here?

    I’m really interested to get some responses because it’s claim that seems, well, insanely idiotic. I’d like some insight.

    • anon_ 412 says:

      Going anonymous to talk about this candidly. There are different “types” of circumcisions (see https://www.circumcision-london.co.uk/circumcision-styles/ for some illustrations. NSFW obviously). As an infant which type you get is obviously unilaterally decided by the doctor. Some types cut away more skin and cause more severe damage than others. This is why people disagree about the lube thing.

      For me, it’s technically possible to masturbate without lube but it causes pain and sometimes bleeding.

      When you say you feel that anyone believing my own day-to-day personal experience is real is “insanely idiotic”, I feel depressed and invalidated. I know you meant it in a spirit of curiosity but it still hurts.

      I thought about not answering this but I think it’s important to provide some insight into what some people feel. Obviously not ALL people who are circumcised need lube, but for some including myself it is a problem. I suspect that a lot of guys are like me but don’t want to talk about it because it’s too depressing to think about. I know that some of my close friends have similar problems, but they have never spoken up about it ever. This isn’t a thing that would ever be recorded in a medical record or statistic, just something that causes very personal and private suffering. Like a lot of sexual abuse, people tend to be quiet about it.

      Is it really that hard to imagine that cutting away a significant amount (in some cases 50%) of the skin of the penis might cause some people problems masturbating?

      • sentientbeings says:

        For me, it’s technically possible to masturbate without lube but it causes pain and sometimes bleeding.

        When you say you feel that anyone believing my own day-to-day personal experience is real is “insanely idiotic”, I feel depressed and invalidated. I know you meant it in a spirit of curiosity but it still hurts.

        I thought about not answering this but I think it’s important to provide some insight into what some people feel.

        Thank for you contributing these comments. It really is surprising to me, and I am glad to have some evidence that it isn’t just some myth contrived by the uninformed.

        I do think that you are (at least partially) mistaken about prevalence and people being quiet about it – I have, admittedly infrequently, discussed the general usage of lubrication before and found that most men (in a highly-circumcised population) found it not only unnecessary, but similarly baffling. There were exceptions though, and I wonder how those individuals might have elaborated given the opportunity for anonymity.

        I would like better statistics on it.

        • anon_ 412 says:

          (my apologies for the long reply. I don’t have the time to make it shorter)

          If you asked me in a non-anonymous setting, I’d just go along with you and not bring up anything about circumcision. I’m simply not going to be comfortable enough talk to you in person, even if we are friends. Perhaps many of your friends are the same; you’d never know.

          I’m especially uncomfortable bringing it up because I know I’ll be ridiculed. Your reaction of incredulity/assuming that problems can’t exist is unfortunately pretty typical. I’ve never been honest with anyone in my entire life (other than my intimate partner) about how deeply circumcision has affected me because of these prevailing attitudes. My partner is circumcised and has similar problems.

          Sexual abuse just works this way. For example: around 1 in 10 girls are sexually abused as children according to https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4311357/. That’s got to be an underestimate since this stuff is under reported. How many women do you know personally? More than 100? Then probably 10-20 of them were sexually abused as children. How many of those women have told you about their abuse? Maybe a few have actually confided in you after a long time. How many do you think would tell you about their abuse if you and essentially all of society started the conversation with “I don’t think child abuse is real, I mean no one I know ever gets abused, right?”

          I think we can get a feel for how many would speak up in that scenario. After all, we used to have the same kind of attitude about child sex abuse as we have about circumcision today. I promise you, it’s absolutely possible for there to be MASSIVE sexual abuse essentially hiding in plain sight. Just look at Scott’s previous post on Van der Kolk’s work, “the Body Keeps the Score”. In Chapter 1, “Lessons from Vietnam Veterans”, he writes:

          …“I was particularly struck by how many female patients spoke of being sexually abused as children. This was puzzling, as the standard textbook of psychiatry at the time stated that incest was extremely rare in the United States, occurring about once in every million women. Given that there were then only about one hundred million women living in the United States, I wondered how forty seven, almost half of them, had found their way to my office in the basement of the hospital.

          Furthermore, the textbook said, “There is little agreement about the role of father-daughter incest as a source of serious subsequent psychopathology.” My patients with incest histories were hardly free of “subsequent psychopathology”—they were profoundly depressed, confused, and often engaged in bizarrely self-harmful behaviors, such as cutting themselves with razor blades. The textbook went on to practically endorse incest, explaining that “such incestuous activity diminishes the subject’s chance of psychosis and allows for a better adjustment to the external world.” In fact, as it turned out, incest had devastating effects on women’s well-being.”

          I know this sounds crazy, but please try to understand that this was really the situation when Van der Kolk began his career! Literally millions of children were being sexually abused and the best medical documents at the time both ignored that it was happening and downplayed the negative effects even if it was happening. I think that something almost exactly analogous with circumcision is happening today.

          One final point. Asking a circumcised man whether they “are fine” is the wrong question. I needed glasses growing up, but I didn’t notice that I needed glasses until someone pointed it out to me! Before then, I just thought I was bad at reading, bad at catching balls, etc. If you asked me then, I would have said that my eyes “were fine”. I simply didn’t have any other reference point, so asking me whether my eyes “were fine” essentially amounts to asking whether they feel worse than yesterday. It’s hard to imagine what functional eyes would feel like without anything to compare to!

          If I can NOT NOTICE that my EYES were SEVERELY DEFECTIVE for literally YEARS, to the point where I needed someone to point it out to me, then how much more so would this sort of effect work for a damaged penis?

          We don’t have anything like an “eye chart” for penises to objectively gauge whether they are functioning well. I think that a lot of circumcised men objectively have problems with their penises, but don’t attribute those problems to their circumcision, the same way that I didn’t connect being bad at reading to a problem with my eyes. This almost has to be the case, given that the limited research we do have shows severe deficits in fine touch sensitivity caused by circumcision (https://www.ncbi.nlm.nih.gov/pubmed/17378847/).

          • onyomi says:

            Great post. I had a similar experience as a kid with my nearsightedness.

            And yes, besides lots of men potentially having psychological and/or physical problems they’re not aware of because they’ve got nothing to compare to, I do think there’s a huge cultural pressure, at least in Anglo-American culture, against men admitting they have a problem or feel emotionally scarred, especially about something so sensitive and connected to masculine pride.

            Asking an American man “is your penis working as well as you’d like and, if not, how do you feel about that?” is probably about as effective at getting honest answers as this.

          • I was also puzzled by the claim about difficulty with masturbation, since it was inconsistent with my experience.

            The claim wasn’t put as “circumcision sometimes has this effect for some men” but as “circumcision has this effect.” (not an actual quote). It doesn’t have that effect for me, so I know that the general statement is false. I would be surprised if the effect is common, not all that surprised that it sometimes exists, as your account clearly implies.

  61. Peter Gerdes says:

    Can anyone explain how the studies on rates of STD transmission controlled for effects of socioeconomic class? Or did they somehow manage to actually look (posthoc) at people in relationships where one party gets diagnosed with an std?

    If not then how? Sure you can regress against income but I’d be very worried circumcision is simply associated with middle/higher class social status and even controlling for race, religion and income you get peoe in one group who have sex with a much safer pool of people (even if they themselves are just as promiscuous or not who they sleep with matters).

  62. Ttar says:

    All the cut guys I know can practically tolerate Brillo pads against their junk compared to what myself and the uncut guys I know can stand.

    Imagine a procedure to reduce the sensitivity of salty and sweet reception on taste buds for infants via cauterization. It results in mildly better health outcomes, and generally people report being just as satisfied after meals regardless of whether they had the procedure or not. Would you cauterize your infant’s taste buds, if it reduces obesity likelihood by a few percent, and only very rarely results in serious speech impediments or total inability to taste?

    • Peter Gerdes says:

      If it made the food last much longer then hell yes I would.

      I don’t know any circumcisced men whose problem is difficulty orgasming during sex. Since sexual pleasure is presumably the integral over time of bodily stim plus mental pleasure combined with general belief that one has made one’s partner happy etc Id notice being less sensitive increases the later and it’s unclear if it increases or decreases former (I’d guess increases since less physical stim allows better fantasizing/dirty talk before orgasm for a given level of hotness

  63. slyme says:

    As someone who was circumcised at 19 by choice after failed attempts to correct phimosis, I still believe that infant circumcision is something I’d prefer avoided.

    I’m not especially aggressive in this stance. I tend to look at it like corporal punishment. I was spanked as a child. I know people who were spanked as a child. None of us were meaningfully harmed by this punishment. Some people will vocally advocate for it, arguing that it helped whip them into shape. But I’m not confident enough in potential positives to ignore the risks. And I’d rather disincentivize a practice that could result an accepted social practice that may beget real harm or long term animosity toward well meaning parents.

    That said, circumcision and recovery as a fully conscious adult is no cake walk. I imagine it might be a harder pill to swallow for people not like me. A healthy amount of detachment directed at the absurdity of lopping off a piece of your penis helps.

  64. keaswaran says:

    I wonder how the result would look if it considered various modifications of female genitalia soon after birth. It seems to me that many discussions of the modifications of genitals of babies soon after birth run together many different types of activities, some of which seem intentionally cruel, others purely symbolic, and some of which may have minor positive or negative medical effects as mentioned here.

  65. Viliam says:

    Coming late to the debate, but… yeah, it felt like the “anti” side was missing completely. Even the most obvious arguments against were missing.

    Then I read the comments “10/10, now I am totally convinced and would shorten my penis immediately” and it feels like I’ve just read a very successful propaganda piece. I suppose it’s because the “pro” side thinks “well, if these are the best arguments the ‘anti’ side can present… then, well, they don’t actually have any arguments”. Just let me say that there are arguments; they are just absent from the article.

    For some reason I am especially irritated by the fact that the “1 in million chance that circumcision would actually prevent a serious disease” gets translated into “400 Americans” to make it more near-mode… but there is mention of complications caused by a botched, mostly useless (really, the actual controversy is between “mostly useless” and “completely useless”) operation, although that seems quite frequent outcome. Similarly, opinions of American pediatrists are relevant, opinions of European ones are not worth of being mentioned.

    The major thing I learned from reading this is: It seems like Americans have a very strong taboo about discussing (or even mentioning) possible negative outcomes of circumcision.

    (To compare, can you imagine an “adversarial collaboration” about vaccination which would completely fail to mention that sometimes vaccination can have a negative impact on someone? Like, the only argument mentioned would be some abstract concern about giving someone an unambiguosly positive treatment without their informed consent, because they are a small baby, duh. That means that anti-vaccination is less controversial than anti-circumcision. Well, at least the anti-vaxers are not routinely accused of anti-Semitism, I guess.)

    One random data point: Last time I participated in an offline debate about circumcision, a women that recently returned from USA said: “Of course circumcision reduces sensitivity to intercourse, that’s why American men are so obsessed with anal sex!”

    • Thegnskald says:

      The comments dig in to the subject better – search for fifty six thousand, as a number with a comma, to get the actual numbers, rather than the incredibly misleading comparison of percentages.

      (The actual numbers are still misleading, mind, because I’m pretty sure “Ended up needing circumcision” is counted as a complication in the uncircumcised side of things, where “Got circumcised” is implicitly uncounted in the uncircumcised side. Also other reasons but I’ve hammered on this topic enough.)

      But yeah, unmodified by the comments, this is just propaganda.

    • onyomi says:

      The major thing I learned from reading this is: It seems like Americans have a very strong taboo about discussing (or even mentioning) possible negative outcomes of circumcision.

      Sunk cost fallacy.

  66. John Schilling says:

    I’ve been trying to turn this into proper consequentialist math, and it’s starting to look like serious complications from childhood UTIs may dominate the pro-circumcision side. Or not, depending on how frequent those complications are and on how much kidney damage it takes to equal one HIV infection or penile cancer. But I’m having a hard time finding data on frequency of serious complications for childhood UTIs that isn’t paywalled. Anybody have good numbers for that?

    If I handwave a 1% rate of major complications for UTIs in infancy, I get ~0.2% of uncircumcised boys/men suffering serious medical conditions at some point in their life that would have been prevented by infant circumcision. “Serious” meaning penile cancer, HIV infection, major kidney damage, and penile injury/infection requiring surgery. Not huge, but not entirely trivial either.

    By comparison, using CDC data I get childhood MMR vaccination preventing serious medical problems in 1.1% of the population; here “serious” means mostly encephalitis, meningitis, and seizures with a scattering of other issues. So, MMR vaccination is a more generally effective prophylactic than circumcision, but probably not an order of magnitude more effective.

    Put me solidly in the “this should be up to the parents, and maybe moderately encouraged by pediatricians” category. Subject to revision if we get better quantitative data to back up the “circumcision ruins people’s sex lives” narrative, but I’m not holding my breath on that.

  67. AnarchyDice says:

    Why is there no mention anywhere in this article what the procedure costs? Surely if you are having a discussion of the harms, benefits, and ethics of something you would mention its cost? Obviously googling exact medical costs are difficult but I found a ballpark number of $300-400. Let’s go with $300. I would guess it is higher if ancillary procedure costs are included, but I see no reason it would be lower than $300.

    From rough estimates of differential rates, it takes roughly 100 circumcisions to avoid one UTI case. That is $30,000 to prevent one UTI treatable with antibiotics. For penile cancer, it takes 100,000 circumcisions to prevent a single case, or $30,000,000! Don’t know how to factor HIV/STI as that is decided by amount and riskiness of sex rather than factors out of the individual’s control like UTI/cancer.

    If the ACC above swung you towards circumcision at all, please stop and do some math first. Base rates and percentiles are giving things a rosier picture than they should.

    *I’m pulling numbers of circumcisions to prevent 1 case from here: https://evidencebasedbirth.com/evidence-and-ethics-on-circumcision/*

  68. Milo Minderbinder says:

    Highly informative, great work! As a circumcised male who had never much considered the issue, I always saw heated online discussion of it as bizarre. Anecdotally, I’ve known three men who were circumcised after becoming sexually active, and all reported neutral-to-positive changes in sensation.

  69. harper says:

    I think this essay presents some interesting evidence about health outcomes. I was surprised the authors did not consider:

    (1) The value of religious or cultural connection. It’s difficult to weigh cultural connection against other more easily quantified (or more universally acknowledged) costs and benefits, but I believe cultural connection is not valueless. I believe (based on testimony in the comments) that cultural connection plays a major role in how people evaluate circumcision. If so, your evaluation of circumcision might vary based on whether circumcision is performed as a cultural rite (which presumably adds some value), or as a mere medical operation (where that additional value is absent). If the health outcomes were neutral or slightly negative or risky, you might consistently, on net, continue to value circumcision whenever it is part of a cultural rite while rejecting it whenever it isn’t.

    (2) The value of bodily autonomy. While similarly difficult to weigh against other more easily quantified costs and benefits, I don’t think bodily autonomy is valueless. I think that based on a careful assessment of the actual risks and benefits involved, some people would prefer to avoid performing circumcision on their children, even if a child who later wants the operation performed as an adult would incur some level of additional risk.

    (3) The fact that the operation irreversibly removes a part of the body. I think some people assume that people who value bodily autonomy value it without exception or nuance, and so being against circumcision is a slippery slope to being against (e.g.) infant vaccines. But it seems reasonable to me to draw a distinction between infant vaccines (which are nondestructive albeit invasive) and circumcision (which is destructive), and that this distinction might reasonably make a difference. I also understand vaccines to be often medically urgent, life-or-death, powerfully effective, and irreplaceable; I think there are some consistent autonomy-prioritizing people who would consistently be in favor of performing destructive operations on their children (limb amputations, circumcision, organ removals, etc.) when and only when these vaccine-like criteria are met, i.e. there’s overriding exigency and the other alternatives seem worse.

    (4) Whether, if circumcision has health benefits, circumcision is the best or only way of achieving those benefits. I might believe that circumcision has health benefits, but that those same health benefits can be achieved to comparable or greater degree or with less risk by other methods. Without that context, deciding whether circumcision is appropriate is (to oversimplify for emphasis) like opting for a particular medicine that beats a placebo without checking whether it beats the best treatment currently available.

    If there are no countervailing interests to measurable health outcomes (cost, time, bodily autonomy, cultural connection, incompatible available alternatives, etc.), then these kinds of trade-offs don’t really matter. For your children, you can just simultaneously pursue all of the best-outcome health procedures at the ages where the procedures are most useful. The evidence in the adversarial collaboration essay is most useful in this kind of situation where we assume that there is only one kind of factor that has value. We can opt for circumcision whenever the evidence points to a reliable positive effect on health outcomes.

    But again, I don’t think these are the only values that matter to people. I see in the comments people for whom circumcision is a wash—they don’t care one way or another, at least for themselves. I want to recognize that for people in this group, the health outcomes in the essay probably cover all you care about. And projecting based on my own read of this essay, I expect that the health outcomes in this essay are furthermore a little boring—either you’re already circumcised, in which case the health outcomes are either positive or not severely bad enough to be actionable; or you’re not circumcised, in which case the health outcomes are not significant enough to be actionable either; or circumcision is inapplicable.

    But I see other people for whom circumcision is a big deal for reasons that are not limited to health, or to the health outcomes of this procedure in isolation. I see people who weigh its cultural significance; those people might prefer to circumcise their children even if the health outcomes were slightly negative. I see people who weigh its invasion of autonomy; those people might prefer e.g. preventing infections using antibiotics over circumcision, even if the health outcomes for circumcision were slightly positive. I see people for whom procedural context matters: if there are (cultural, health, …) benefits to circumcision, are those benefits attainable by other means? Do they vary based on geography? How do those other means compare in terms of efficacy and risk?

    Overall, I feel like this essay has collected a fairly un-adversarial collection of evidence about health outcomes relating to circumcision. Even if the authors were intent on just adversarially answering “What are the health-specific benefits, costs, and risks of infant circumcision in the US?” rather than “What are the factors, and corresponding facts of the world, that should be weighed when choosing whether to circumcise your child?”, I wish they had supplied additional medical context by comparing against baselines and alternative means of achieving particular benefits. Supplying baselines and alternatives can be important grist for people of many different value systems.

  70. briandavidearp says:

    Hello, my name is Brian Earp; I am Associate Director of the Yale-Hastings Program in Ethics and Health Policy at Yale University and The Hastings Center. I was co-editor of a special issue on the science and ethics circumcision in the Journal of Medical Ethics, published by the BMJ, and this topic is my main area of academic specialization. I would like to congratulate the authors on giving a much more nuanced discussion of the scientific (and some of ethical) considerations than one normally finds in popular venues. I hope I may also offer some constructive criticism about certain points as well as direct any interested readers to additional resources they may want to check out.

    As a starting point, for example, I recommend the most recent comprehensive review of the medical literature and recent ethical debates available from Evidence Based Birth, which addresses each empirical claim in the present post in considerable detail, giving adequate context and providing appropriate qualifications regarding evidence quality, alternative methods of prevention or treatment, and so on. The authors write, “After an extensive review of the literature, we’ve concluded that there is no compelling evidence to justify routine male infant circumcision on medical grounds.” Regarding specific claims, here are some thoughts (drawn primarily from this in-press paper with a colleague).

    Penile cancer. According to recent estimates, “penile cancer is one of the rarest malignancies for which site-specific data are available in cancer registries. In 2003–2007, penile cancers accounted for 0.15% of all incident cancers in the United States, thus ranking 43rd in incidence among all site-specific cancers in US males.” In fact, penile cancer “is not among the 10 most common malignancies in males in any national cancer registry; even in high-incidence regions of South America, Africa, and Asia, the risk of developing penile cancer before age 75 years is below 0.4%.” In line with this, the American Academy of Pediatrics (AAP) estimates that between 909 and 322,000 circumcisions would be required to prevent a single case. Yet the main risk factors for penile cancer are not simply having surgically unmodified genitalia. There usually has to be some further thing wrong with the penis or foreskin, and this can nearly always be prevented or treated without resorting to circumcision. The authors of the present post mention phimosis, for example. This just means the inability to retract the foreskin. However, in young boys, a non-retractile foreskin is normal as the foreskin is fused to the glans at birth, after which the two structures gradually separate during early childhood. In approximately 50% of cases, this process will be complete by ten years of age, but it can continue until after the onset of puberty. For this reason, phimosis, as such, is difficult to accurately diagnose before adolescence; in any case, it is recurrent, pathological phimosis — specifically — that seems to be related to an increased risk of penile cancer. Yet if a lack of ability to retract the foreskin does create problems for a child, this can usually be treated in a less invasive way than by simply excising the foreskin altogether: topical creams and gentle stretching will resolve the majority of problematic cases with no cutting of tissue required, and most of the remainder can be addressed with foreskin-preserving preputioplasty (for instance, a limited dorsal slit with transverse closure). Since there are less invasive yet effective ways of reducing the risk of penile cancer (which is a very small absolute risk to begin with) than pre-emptive, non-consensual removal of healthy genital tissue, the latter cannot be advised even on medical grounds.

    HIV and STIs. As noted, the only reasonably well-controlled evidence for a partially protective effect against HIV transmission comes from studies of adult men circumcised voluntarily in sub-Saharan Africa, where there is an epidemic of heterosexually-transmitted HIV. By contrast, there is *no* good-quality evidence that non-consensual, neonatal circumcision in developed countries with radically different disease transmission patterns (plus greater access to effective pre-exposure prophylaxis etc.) has any protective effect against HIV. But even assuming, contrary to reality, that the adult African data could be simply copied and pasted onto non-consensual circumcision in very different epidemiological environments, such as the US (where most HIV infections are not heterosexually transmitted, but are confined to injecting drug users and men who have sex with men), this would not count as a reason to perform such circumcision. Sarah Bundick has argued as follows:

    If we assume that all 5,250 men who get HIV from a female sexual partner [per year] are not circumcised (though this is certainly not the case), the data suggest that about half of these infections — around 2,625 infections or ~5% of new infections — may have been prevented if the men had been circumcised. If we then factor in the number of men who are circumcised when they are infected (approximately 70-80% of American men are already circumcised), the number of infections that could have been prevented by circumcision drops considerably. Taken together, the data suggest that the number of HIV infections that could be prevented in the US by promoting infant male circumcision is likely to be only in the hundreds per year — a tiny fraction of the estimated 50,000 new HIV infections.

    A final note about HIV. The authors of the post cite 3 RCTs, which looked at female-to-male transmission of HIV. But unless I missed it, they don’t cite the 4th trial that was conducted, which looked at male to female transmission of HIV as a consequence of penile circumcision. This trial was stopped early due to “futility” with female partners of circumcised men becoming infected with HIV at a *higher* rate than female partners of genitally intact men; and yet women in sub-Saharan Africa are far more vulnerable to HIV than men. See Wawer, M. J., Makumbi, K., Kigozi, G., et al. (2009). Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet, 374(9685): 229-237.

    Regarding other STIs, the authors of the post note that the data are even less compelling than for HIV, so I won’t take up space going into the evidence in detail. But even one finds the HIV/STI data compelling, these risks can be more effectively reduced without surgery, and the risk-reduction would not apply until sexual debut, which is typically at, near, or after the time at which the vast majority of individuals could consent to circumcision if that is what they wanted. In short, when a potential health benefit can be achieved either via (1) a non-voluntary surgical procedure performed on an individual to whom the benefit does not currently apply, and likely will not apply for many years (if at all); or (2) a similar surgical procedure undertaken voluntarily by the same individual when that individual is a position to decide whether the benefit is actually applicable (and if it is, whether it is worth the medical and non-medical risks given their known values/preferences and the available non-surgical alternatives); it is not normally justified, even on medical grounds, to proceed with option (1).

    UTIs and balanitis. This claimed benefit has never been studied via RCT, but observational and cohort studies, if their results are taken at face value, do suggest that UTIs are anywhere between three and ten times more likely to occur in genitally intact male infants under 2 years of age than in circumcised ones. A problem with interpreting such figures is that the rate of false positives may be higher for diagnoses among the former group than the latter, as the authors note. But even if one takes such figures for granted, the difference between absolute and relative risk needs to be highlighted. According to recent estimates from the American Academy of Pediatrics (AAP), UTIs affect roughly 1% of boys in the first two years of life regardless of circumcision status, suggesting that “the number needed to circumcise to prevent [one] UTI is approximately 100.” However, rather than permanently excising a sensitive genital structure from 100—or even far fewer—healthy boys to prevent one of them from acquiring a UTI, the same hypothetical UTI could be safely, successfully, and non-invasively treated with antibiotics in most cases. This is the standard of care for girls, who are about 4 to 8 times more likely than boys to acquire a UTI by age 5 years, according to the AAP. Balanitis (or inflammation of the glans penis) is also thought to occur less often in circumcised males, although it may actually be more common in such males while they are still in diapers. According to the UK National Health Service, balanitis is “not usually serious” and “most cases [are] easily treated with good hygiene and creams [or] ointments.” Again, it is not clear why indiscriminately removing genital tissue from healthy infants to—potentially—reduce the risk of a typically non-serious and easily treatable source of temporary discomfort should even be entertained, on either medical or ethical grounds.

    Risks of surgery — greater in infancy or later? Several thoughts here. First, because the infant penis is so small, the physician performing the circumcision may remove too much tissue, possibly contributing to tight or painful erections in adulthood, without being able to anticipate or fully account for this adverse outcome. It may also be more likely that the frenulum would be cut away with those devices most commonly used to perform a neonatal or infant circumcisions (e.g., the Gomco clamp, Mogen clamp, or Plastibell), which less discriminately remove tissue around the diminutive infant glans. In voluntary circumcisions, by contrast—that is, when the penis has reached its full size—it is easier for the physician to cut around the frenulum, leaving it mostly or entirely intact. In terms of data collection and estimation of complications, problems associated with newborn circumcision may be less likely to be recognized or reported: some individuals may go their entire lives thinking that a negative outcome is normal, or fail to associate the problem with their circumcision, since this occurred prior to their ability to make a conscious before-and-after comparison. Finally, the infant foreskin is normally fused to the head of the penis by a membrane, whereas the foreskin of a fully developed penis is more likely to be detached. The authors of a study comparing neonatal circumcision with that of older boys explain the surgical significance of this distinction:

    In the neonatal period, irrespective of the applied method of circumcision, a forced and traumatic degloving of the foreskin from the meatus, glans, and sulcus cannot be avoided … Initially, the inner surface of the prepuce and the epithelium of the glans are fused, and separation of these two surfaces develops progressively [which] explains the need for forceful and traumatic degloving in neonatal circumcision. Degloving leads to a perimeatal inflammation, which can result in meatal deformity with eventual stenosis. Development of scar tissue with meatal deformity and stenosis [in our study] was secondary to the traumatic excoriation and was not merely due to exposure and irritation by the diaper of the fragile and under-keratinized glans epithelium.

    Even from a purely technical perspective, then, there are at least some costs to performing circumcision on a small and underdeveloped penis that do not apply to circumcision performed on a penis that has reached its full size and final configuration. Moreover, any long-term complications that are incurred in infancy or early childhood will affect the individual for a longer period of time and hence a greater proportion of their life compared to the same complication incurred in adolescence or adulthood.

    A popular claim, from this paper, is that “evidence clearly shows that circumcision in infancy carries fewer risks of complications than circumcisions performed in childhood or later in life.” Somewhat incongruously, however, these authors go on to argue, in a similar vein as the authors of the post,

    A recent systematic review found a median complication frequency of 1.5% among studies of neonatal or infant circumcision, compared to 6% among studies of children aged one year or older … In the large RCTs of adult MC, complications were seen in 1.7-3.8%; these were virtually all mild or moderate and were effectively treated.

    In other words, according to these authors, while complications from circumcision in early childhood (ages 1 year and older) occur about 4 times as frequently as in the neonatal or infant period—assuming that the cited data are correct; more on this below—there does not appear to be a very large absolute difference between complications arising from such neonatal or infant circumcision and adult circumcision, which is the more ethically relevant comparison in terms of the capacity to consent. In fact, even the relative difference in complication rates appears to be modest: the complication rate for adult circumcision, according to the authors, is between 1.13 and 2.53 times that of NNMC, with “virtually all” of the complications associated with the adult form being “mild or moderate” and “effectively treated.” If that is the case, then the marginally greater alleged complication rate in adults (in absolute terms, between 0.2% and 2.3%) is arguably of little medical or ethical significance; whereas the capacity of the adult, compared to the infant, to consent to the procedure is of enormous ethical significance. Even so, the evidence cited by in support of claims regarding an increased risk for adults does not come from well-controlled studies. Instead, it comes from studies of non-concurrent populations circumcised with different techniques and evaluated with disparate methodologies, using inconsistent definitions and thresholds for identifying complications.

    That being said, recent findings from a relatively controlled comparison based on millions of cases, with all circumcisions performed as part of the ongoing circumcision-for-HIV program described in the post, suggest the very opposite of the conclusion drawn by the authors. According to the U.S President’s Emergency Plan for AIDS Relief (PEPFAR), “Complications continue to be reported more commonly among those under age 15 at VMMC, especially in infants.” In particular, fully 100% of glans injuries and 90% of fistulas reported through their Notable Adverse Events (NAE) reporting system occurred in children circumcised at ages 14 and younger. And the overall ratio NAEs to circumcisions performed was five times higher in infants (15.3 per 100,000) than in young adolescents (2.9 per 100,000), which in turn was about twice the ratio for individuals circumcised at ages 15 years and above (1.6 per 100,000). As a result of these findings, PEPFAR announced in late 2019 that it will no longer fund infant circumcisions as a part of the VMMC program, citing the “NAE review, the severity of glans injuries and fistulas when they occur, and expected timing of pubertal development.” The minimum eligibility criteria for VMMC have been updated to 15 years of age or Tanner Stage 3 sexual development.

    Even in developed countries, severe complications associated with newborn circumcision may be more common than suggested by its proponents’ conservative estimates. At a single children’s hospital in Birmingham, England, for instance, cases of “life threatening hemorrhage, shock or sepsis” resulting from infant circumcision ranged from 0 to 11 per year between 2002 and 2011. Since these figures were obtained due to a special freedom of information request and otherwise would not have been made public, it is unclear whether the complication rates in the published literature reflect the full scope of the problem. Finally, it has been suggested that “the severity of complications is far more important than the rate. Although necrotizing fasciitis, amputation of the penis and death are incredibly rare,” they may be more common in infancy than in adulthood (assuming a similar clinical context and a healthy organ); and “some would consider it unethical [to] advocate for an elective procedure that may or may not benefit an individual [non-consenting] patient yet has any potential to result in such devastating outcomes.”

    Sexual outcome variables. The authors write that “Sexual satisfaction, particularly in sexually active heterosexual men, seems to be unchanged with adult circumcision. During studies of adult circumcision for HIV prevention, in which large numbers of men were randomized to receive circumcision at the time of the study or after, sexual satisfaction of did not significantly differ between the two groups.” There are a couple of issues with this. First, the quality of the materials in those studies have been criticized in the literature as follows: “it should be recalled that a strong study design, such as a randomized controlled trial, does not offset the need for high-quality questionnaires. Having obtained the questionnaires from the authors … I am not surprised that these studies provided little evidence of a link between circumcision and various sexual difficulties. Several questions were too vague to capture possible differences between circumcised and not-yet circumcised participants (e.g. lack of a clear distinction between intercourse and masturbation-related sexual problems and no distinction between premature ejaculation and trouble or inability to reach orgasm). Thus, non-differential misclassification of sexual outcomes in these African trials probably favored the null hypothesis of no difference, whether an association was truly present or not.”

    But even if one simply accepts the results from those studies as being of highest quality because of the large sample size and randomized design, this would not count in favor of non-consensual circumcision. This is because these studies concerned consensual, adult circumcision, not circumcision of newborns. If anything, then, their data support the performance of voluntary circumcision after an age of consent: for it is circumcision of this kind for which the evidence against adverse sexual outcomes is, on this argument, the strongest.

    Of course, comprehensively assessing both the objective and subjective sexual outcomes of specifically newborn circumcision in a nuanced, scientific way is exceedingly difficult, and as such has never been done. Moreover, proving a negative claim about adverse sexual outcomes is practically impossible: an absence of evidence is not the same thing as evidence of absence unless one has accurately, robustly, and systematically measured all such possible outcomes with sufficient statistical power to detect them, should they exist. Obviously this has not occurred. Moreover, there are many aspects of the foreskin that are not yet fully understood, and increasing evidence that circumcision likely does alter subjective sexual experience in a variety of ways. These alterations might not always be judged negatively: some men circumcised as adults, for instance, have indeed reported no difference or even an increase in sexual satisfaction, while other men have noted a clear decrease, as in the Korean study mentioned by the authors. The point is that no one other than the owner of the penis is better positioned to determine whether they wish to assume the risk that circumcision might permanently compromise their sexual enjoyment. A person who seeks circumcision in adulthood also has the advantage of being able to explain to the surgeon exactly how they want the procedure performed. They are able to choose the “style” of cut that conforms to their own aesthetic preferences (e.g., “high and tight” or “low and loose”), and because their penis is fully grown, the surgeon will be able to determine with precision its final or stable anatomy, vasculature and innervation. In infancy, the penis is very small and the surgeon cannot know how big the organ will grow or exactly where to do the cutting in order to obtain the desired cosmetic result. Because this is essentially a guess, too much tissue is sometimes removed; or indeed too little tissue, such that re-operation may be pursued. I have a 20 minute or so lecture on specifically the question of whether circumcision counts as a sexual harm for anyone interested, here: https://www.youtube.com/watch?v=SB-2aQoTQeA. You might also want to check out the paper, “Circumcision, Sexual Experience, and Harm” by a colleague and me.

    Ethics. I recommend the paper, “Medically Unnecessary Genital Cutting and the Rights of the Child,” an international consensus paper on the ethical issues published just last month, which I co-authored with about 90 mostly senior scholars in medicine, law, ethics, human rights, and other areas, with special expertise in genital cutting. We write, “Under most conditions, cutting any person’s genitals without their informed consent is a serious violation of their right to bodily integrity. As such, it is morally impermissible unless the person is nonautonomous (incapable of consent) and the cutting is medically necessary … a common understanding is that an intervention to alter a bodily state is medically necessary when (1) the bodily state poses a serious, time-sensitive threat to the person’s well-being, typically due to a functional impairment in an associated somatic process, and (2) the intervention, as performed without delay, is the least harmful feasible means of changing the bodily state to one that alleviates the threat. ‘Medically necessary’ is therefore different from ‘medically beneficial,’ a weaker standard, which requires only that the expected health-related benefits outweigh the expected health-related harms. The latter ratio is often contested as it depends on the specific weights assigned to the potential outcomes of the intervention, given, among other things, (a) the subjective value to the individual of the body parts that may be affected, (b) the individual’s tolerance for different kinds or degrees of risk to which those body parts may be exposed, and (c) any preferences the individual may have for alternative (e.g., less invasive or risky) means of pursuing the intended health-related benefits. We argue that although the weaker, ‘medically beneficial’ standard may well be appropriate for certain interventions into the body, it is not appropriate for cutting or removing healthy tissue from the genitals of a nonconsenting person. If someone is capable of consenting to genital cutting but declines to do so, no type or degree of expected benefit, health-related or otherwise, can ethically justify the imposition of such cutting. If, by contrast, a person is not even capable of consenting due to a temporary lack of sufficient autonomy (e.g., an intoxicated adult or a young child), there are strong moral reasons in the absence of a relevant medical emergency to wait until the person acquires the capacity to make their own decision.”

    The best argument for this view might be made by way of analogy. Consider a different example, that of labiaplasty. Labiaplasty is similar to circumcision in that it removes genital tissue that is not necessary for sexual enjoyment but which nevertheless has certain properties—sensitivity to touch, elasticity, independent manipulability, and so forth—that allow for particular subjective sensations, during sex or foreplay, for example, that many people value positively. It is also similar to circumcision in that the genital tissue it removes is often warm and moist and may trap bacteria, can become infected or even cancerous, may be injured or torn during sexual activity, and requires regular washing to maintain good hygiene. Removing the labia, therefore, likely does confer at least some statistical health benefits in that it reduces the surface area of genital tissue that is not essential for sexual function (in some narrow sense) but which may on occasion pose a problem of one kind or another for its owner. In addition, it may plausibly confer at least some psychological or social benefits for some women, insofar as they prefer the aesthetics of a vulva that has been subjected to labiaplasty, or if it helps them avoid negative judgments from potential sexual partners (however inappropriate such judgments may be). Indeed, the World Health Organization (WHO) includes such broader psychosocial factors in its definition of health, so perhaps these potential outcomes should be counted as “health benefits” as well.

    Now, let us assume for the sake of argument that performing labiaplasty in infancy is technically simpler, safer, and more cost effective—with a shorter healing time, and so on—than labiaplasty performed on a consenting adult. Would any of these considerations, alone or together, make non-voluntary neonatal labiaplasty permissible, either morally or legally, in Western societies? It seems unlikely. As I have argued elsewhere, even if health benefits of some kind or degree do one day become reliably associated with neonatal labiaplasty, it is almost certain that opponents of the practice (which includes the WHO, the United Nations, all Western democracies, and myself) would continue to see clear moral problems:

    First, they would argue that healthy tissue is valuable in-and-of-itself, so should be counted in the “harm” column simply by virtue of being damaged or removed. Second, they would point to non-surgical means of preventing or treating infections, and suggest that these should be favored over more invasive methods. And third, they would bring up the language of rights: a girl has a right to grow up with her genitals intact, they would say, and decide for herself at an age of understanding whether she would like to have parts of them cut into or cut off.

    The same arguments, I suggest, apply to male circumcision.

    Main reference

    Myers, A., & Earp, B. D. (in press). What is the best age to circumcise? A medical and ethical analysis. Bioethics, in press. Available from https://www.researchgate.net/publication/337720859_What_is_the_best_age_to_circumcise_A_medical_and_ethical_analysis (you have to request the text because I’m not allowed to publicly post it yet).

    Other hopefully useful writings from my colleagues and me discussing the ethics in light of both the science and normative considerations

    Earp, B. D. (2015). Female genital mutilation and male circumcision: toward an autonomy-based ethical
    framework. Medicolegal and Bioethics, 5(1), 89-104.

    Earp, B. D. (2016). Infant circumcision and adult penile sensitivity: implications for sexual experience. Trends in Urology & Men’s Health, 7(4), 17-21.

    Earp, B. D., & Darby, R. (2017). Circumcision, sexual experience, and harm. University of Pennsylvania Journal of International Law, 37(2 – online), 1-56.

    Earp, B. D. & Shaw, D. M. (2017). Cultural bias in American medicine: the case of infant male circumcision. Journal of Pediatric Ethics, 1(1), 8-26.

    Earp, B. D., & Steinfeld, R. (2018). Genital autonomy and sexual well-being. Current Sexual Health Reports, 10(1), 7-17.

    Frisch, M.#, & Earp, B. D.# (2018). Circumcision of male infants and children as a public health measure in developed countries: a critical assessment of recent evidence. Global Public Health, 13(5), 626-641.

  71. briandavidearp says:

    Hello, my name is Brian Earp; I am Associate Director of the Yale-Hastings Program in Ethics and Health Policy at Yale University and The Hastings Center. I was co-editor of a special issue on the science and ethics of circumcision in the Journal of Medical Ethics, published by the BMJ, and this topic is my main area of academic specialization. I would like to congratulate the authors on giving a much more nuanced discussion of the scientific (and some of ethical) considerations than one normally finds in popular venues. I hope I may also offer some constructive criticism about certain points as well as direct any interested readers to additional resources they may want to check out.

    As a starting point, for example, I recommend the most recent comprehensive review of the medical literature and recent ethical debates available from Evidence Based Birth (https://evidencebasedbirth.com/evidence-and-ethics-on-circumcision/), which addresses each empirical claim in the present post in considerable detail, giving adequate context and providing appropriate qualifications regarding evidence quality, alternative methods of prevention or treatment, and so on. The authors write, “After an extensive review of the literature, we’ve concluded that there is no compelling evidence to justify routine male infant circumcision on medical grounds.”

    Regarding specific claims, here are some thoughts, drawn primarily from an in-press paper with a colleague (cited at the end of this comment; primary sources are within).

    Penile cancer. According to recent estimates, “penile cancer is one of the rarest malignancies for which site-specific data are available in cancer registries. In 2003–2007, penile cancers accounted for 0.15% of all incident cancers in the United States, thus ranking 43rd in incidence among all site-specific cancers in US males.” In fact, penile cancer “is not among the 10 most common malignancies in males in any national cancer registry; even in high-incidence regions of South America, Africa, and Asia, the risk of developing penile cancer before age 75 years is below 0.4%.” In line with this, the American Academy of Pediatrics (AAP) estimates that between 909 and 322,000 circumcisions would be required to prevent a single case.

    Yet the main risk factors for penile cancer are not simply having surgically unmodified genitalia. There usually has to be some further thing wrong with the penis or foreskin, and this can nearly always be prevented or treated without resorting to circumcision.

    The authors of the present post mention phimosis, for example. This just means the inability to retract the foreskin. However, in young boys, a non-retractile foreskin is normal as the foreskin is fused to the glans at birth, after which the two structures gradually separate during early childhood. In approximately 50% of cases, this process will be complete by ten years of age, but it can continue until after the onset of puberty. For this reason, phimosis, as such, is difficult to accurately diagnose before adolescence; in any case, it is recurrent, pathological phimosis — specifically — that seems to be related to an increased risk of penile cancer. Yet if a lack of ability to retract the foreskin does create problems for a child, this can usually be treated in a less invasive way than by simply excising the foreskin altogether: topical creams and gentle stretching will resolve the majority of problematic cases with no cutting of tissue required, and most of the remainder can be addressed with foreskin-preserving preputioplasty (for instance, a limited dorsal slit with transverse closure).

    Since there are less invasive yet effective ways of reducing the risk of penile cancer (which is a very small absolute risk to begin with) than pre-emptive, non-consensual removal of healthy genital tissue, the latter cannot be advised even on medical grounds.

    HIV and STIs. As noted, the only reasonably well-controlled evidence for a partially protective effect against HIV transmission comes from studies of adult men circumcised voluntarily in sub-Saharan Africa, where there is an epidemic of heterosexually-transmitted HIV. By contrast, there is *no* good-quality evidence that non-consensual, neonatal circumcision in developed countries with radically different disease transmission patterns (plus greater access to effective pre-exposure prophylaxis etc.) has any protective effect against HIV. But even assuming, contrary to reality, that the adult African data could be simply copied and pasted onto non-consensual circumcision in very different epidemiological environments, such as the US (where most HIV infections are not heterosexually transmitted, but are confined to injecting drug users and men who have sex with men), this would not count as a reason to perform such circumcision. Sarah Bundick has argued as follows:

    If we assume that all 5,250 men who get HIV from a female sexual partner [per year] are not circumcised (though this is certainly not the case), the data suggest that about half of these infections — around 2,625 infections or ~5% of new infections — may have been prevented if the men had been circumcised. If we then factor in the number of men who are circumcised when they are infected (approximately 70-80% of American men are already circumcised), the number of infections that could have been prevented by circumcision drops considerably. Taken together, the data suggest that the number of HIV infections that could be prevented in the US by promoting infant male circumcision is likely to be only in the hundreds per year — a tiny fraction of the estimated 50,000 new HIV infections.

    A final note about HIV. The authors of the post cite 3 RCTs, which looked at female-to-male transmission of HIV. But unless I missed it, they don’t cite the 4th trial that was conducted, which looked at male to female transmission of HIV as a consequence of penile circumcision. This trial was stopped early due to “futility” with female partners of circumcised men becoming infected with HIV at a *higher* rate than female partners of genitally intact men; and yet women in sub-Saharan Africa are far more vulnerable to HIV than men. See Wawer, M. J., Makumbi, K., Kigozi, G., et al. (2009). Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet, 374(9685): 229-237.

    Regarding other STIs, the authors of the post note that the data are even less compelling than for HIV, so I won’t take up space going into the evidence in detail. But even one finds the HIV/STI data compelling, these risks can be more effectively reduced without surgery, and the risk-reduction would not apply until sexual debut, which is typically at, near, or after the time at which the vast majority of individuals could consent to circumcision if that is what they wanted.

    In short, when a potential health benefit can be achieved either via (1) a non-voluntary surgical procedure performed on an individual to whom the benefit does not currently apply, and likely will not apply for many years (if at all); or (2) a similar surgical procedure undertaken voluntarily by the same individual when that individual is a position to decide whether the benefit is actually applicable (and if it is, whether it is worth the medical and non-medical risks given their known values/preferences and the available non-surgical alternatives); it is not normally justified, even on medical grounds, to proceed with option (1).

    UTIs and balanitis. This claimed benefit has never been studied via RCT, but observational and cohort studies, if their results are taken at face value, do suggest that UTIs are anywhere between three and ten times more likely to occur in genitally intact male infants under 2 years of age than in circumcised ones. A problem with interpreting such figures is that the rate of false positives may be higher for diagnoses among the former group than the latter, as the authors note. But even if one takes such figures for granted, the difference between absolute and relative risk needs to be highlighted. According to recent estimates from the American Academy of Pediatrics (AAP), UTIs affect roughly 1% of boys in the first two years of life regardless of circumcision status, suggesting that “the number needed to circumcise to prevent [one] UTI is approximately 100.”

    However, rather than permanently excising a sensitive genital structure from 100—or even far fewer—healthy boys to prevent one of them from acquiring a UTI, the same hypothetical UTI could be safely, successfully, and non-invasively treated with antibiotics in most cases. This is the standard of care for girls, who are about 4 to 8 times more likely than boys to acquire a UTI by age 5 years, according to the AAP.

    Balanitis (or inflammation of the glans penis) is also thought to occur less often in circumcised males, although it may actually be more common in such males while they are still in diapers. According to the UK National Health Service, balanitis is “not usually serious” and “most cases [are] easily treated with good hygiene and creams [or] ointments.” Again, it is not clear why indiscriminately removing genital tissue from healthy infants to—potentially—reduce the risk of a typically non-serious and easily treatable source of temporary discomfort should even be entertained, on either medical or ethical grounds.

    Risks of surgery — greater in infancy or later? Several thoughts here. First, because the infant penis is so small, the physician performing the circumcision may remove too much tissue, possibly contributing to tight or painful erections in adulthood, without being able to anticipate or fully account for this adverse outcome. It may also be more likely that the frenulum would be cut away with those devices most commonly used to perform a neonatal or infant circumcisions (e.g., the Gomco clamp, Mogen clamp, or Plastibell), which less discriminately remove tissue around the diminutive infant glans. In voluntary circumcisions, by contrast—that is, when the penis has reached its full size—it is easier for the physician to cut around the frenulum, leaving it mostly or entirely intact.

    In terms of data collection and estimation of complications, problems associated with newborn circumcision may be less likely to be recognized or reported: some individuals may go their entire lives thinking that a negative outcome is normal, or fail to associate the problem with their circumcision, since this occurred prior to their ability to make a conscious before-and-after comparison.

    Finally, the infant foreskin is normally fused to the head of the penis by a membrane, whereas the foreskin of a fully developed penis is more likely to be detached. The authors of a study comparing neonatal circumcision with that of older boys explain the surgical significance of this distinction:

    In the neonatal period, irrespective of the applied method of circumcision, a forced and traumatic degloving of the foreskin from the meatus, glans, and sulcus cannot be avoided … Initially, the inner surface of the prepuce and the epithelium of the glans are fused, and separation of these two surfaces develops progressively [which] explains the need for forceful and traumatic degloving in neonatal circumcision. Degloving leads to a perimeatal inflammation, which can result in meatal deformity with eventual stenosis. Development of scar tissue with meatal deformity and stenosis [in our study] was secondary to the traumatic excoriation and was not merely due to exposure and irritation by the diaper of the fragile and under-keratinized glans epithelium.

    Even from a purely technical perspective, then, there are at least some costs to performing circumcision on a small and underdeveloped penis that do not apply to circumcision performed on a penis that has reached its full size and final configuration. Moreover, any long-term complications that are incurred in infancy or early childhood will affect the individual for a longer period of time and hence a greater proportion of their life compared to the same complication incurred in adolescence or adulthood.

    A popular claim, from this paper (https://www.ncbi.nlm.nih.gov/pubmed/22373281), is that “evidence clearly shows that circumcision in infancy carries fewer risks of complications than circumcisions performed in childhood or later in life.” Somewhat incongruously, however, these authors go on to argue, in a similar vein as the authors of the post,

    A recent systematic review found a median complication frequency of 1.5% among studies of neonatal or infant circumcision, compared to 6% among studies of children aged one year or older … In the large RCTs of adult MC, complications were seen in 1.7-3.8%; these were virtually all mild or moderate and were effectively treated.

    In other words, according to these authors, while complications from circumcision in early childhood (ages 1 year and older) occur about 4 times as frequently as in the neonatal or infant period—assuming that the cited data are correct; more on this below—there does not appear to be a very large absolute difference between complications arising from such neonatal or infant circumcision and adult circumcision, which is the more ethically relevant comparison in terms of the capacity to consent. In fact, even the relative difference in complication rates appears to be modest: the complication rate for adult circumcision, according to the authors, is between 1.13 and 2.53 times that of NNMC, with “virtually all” of the complications associated with the adult form being “mild or moderate” and “effectively treated.”

    If that is the case, then the marginally greater alleged complication rate in adults (in absolute terms, between 0.2% and 2.3%) is arguably of little medical or ethical significance; whereas the capacity of the adult, compared to the infant, to consent to the procedure is of enormous ethical significance.

    Even so, the evidence cited by in support of claims regarding an increased risk for adults does not come from well-controlled studies. Instead, it comes from studies of non-concurrent populations circumcised with different techniques and evaluated with disparate methodologies, using inconsistent definitions and thresholds for identifying complications.

    That being said, recent findings from a relatively controlled comparison based on millions of cases, with all circumcisions performed as part of the ongoing circumcision-for-HIV program described in the post, suggest the very opposite of the conclusion drawn by the authors. According to the U.S President’s Emergency Plan for AIDS Relief (PEPFAR), “Complications continue to be reported more commonly among those under age 15 at VMMC, especially in infants.” In particular, fully 100% of glans injuries and 90% of fistulas reported through their Notable Adverse Events (NAE) reporting system occurred in children circumcised at ages 14 and younger. And the overall ratio NAEs to circumcisions performed was five times higher in infants (15.3 per 100,000) than in young adolescents (2.9 per 100,000), which in turn was about twice the ratio for individuals circumcised at ages 15 years and above (1.6 per 100,000).

    As a result of these findings, PEPFAR announced in late 2019 that it will no longer fund infant circumcisions as a part of the VMMC program, citing the “NAE review, the severity of glans injuries and fistulas when they occur, and expected timing of pubertal development.” The minimum eligibility criteria for VMMC have been updated to 15 years of age or Tanner Stage 3 sexual development.

    Even in developed countries, severe complications associated with newborn circumcision may be more common than suggested by its proponents’ conservative estimates. At a single children’s hospital in Birmingham, England, for instance, cases of “life threatening hemorrhage, shock or sepsis” resulting from infant circumcision ranged from 0 to 11 per year between 2002 and 2011. Since these figures were obtained due to a special freedom of information request and otherwise would not have been made public, it is unclear whether the complication rates in the published literature reflect the full scope of the problem.

    Finally, it has been suggested that “the severity of complications is far more important than the rate. Although necrotizing fasciitis, amputation of the penis and death are incredibly rare,” they may be more common in infancy than in adulthood (assuming a similar clinical context and a healthy organ); and “some would consider it unethical [to] advocate for an elective procedure that may or may not benefit an individual [non-consenting] patient yet has any potential to result in such devastating outcomes.”

    Sexual outcome variables. The authors write that “Sexual satisfaction, particularly in sexually active heterosexual men, seems to be unchanged with adult circumcision. During studies of adult circumcision for HIV prevention, in which large numbers of men were randomized to receive circumcision at the time of the study or after, sexual satisfaction of did not significantly differ between the two groups.” There are a couple of issues with this. First, the quality of the materials in those studies have been criticized in the literature as follows: “it should be recalled that a strong study design, such as a randomized controlled trial, does not offset the need for high-quality questionnaires. Having obtained the questionnaires from the authors … I am not surprised that these studies provided little evidence of a link between circumcision and various sexual difficulties. Several questions were too vague to capture possible differences between circumcised and not-yet circumcised participants (e.g. lack of a clear distinction between intercourse and masturbation-related sexual problems and no distinction between premature ejaculation and trouble or inability to reach orgasm). Thus, non-differential misclassification of sexual outcomes in these African trials probably favored the null hypothesis of no difference, whether an association was truly present or not.”

    But even if one simply accepts the results from those studies as being of highest quality because of the large sample size and randomized design, this would not count in favor of non-consensual circumcision. This is because these studies concerned consensual, adult circumcision, not circumcision of newborns. If anything, then, their data support the performance of voluntary circumcision after an age of consent: for it is circumcision of this kind for which the evidence against adverse sexual outcomes is, on this argument, the strongest.

    Of course, comprehensively assessing both the objective and subjective sexual outcomes of specifically newborn circumcision in a nuanced, scientific way is exceedingly difficult, and as such has never been done. Moreover, proving a negative claim about adverse sexual outcomes is practically impossible: an absence of evidence is not the same thing as evidence of absence unless one has accurately, robustly, and systematically measured all such possible outcomes with sufficient statistical power to detect them, should they exist. Obviously this has not occurred.

    Moreover, there are many aspects of the foreskin that are not yet fully understood, and increasing evidence that circumcision likely does alter subjective sexual experience in a variety of ways. These alterations might not always be judged negatively: some men circumcised as adults, for instance, have indeed reported no difference or even an increase in sexual satisfaction, while other men have noted a clear decrease, as in the Korean study mentioned by the authors. The point is that no one other than the owner of the penis is better positioned to determine whether they wish to assume the risk that circumcision might permanently compromise their sexual enjoyment. A person who seeks circumcision in adulthood also has the advantage of being able to explain to the surgeon exactly how they want the procedure performed. They are able to choose the “style” of cut that conforms to their own aesthetic preferences (e.g., “high and tight” or “low and loose”), and because their penis is fully grown, the surgeon will be able to determine with precision its final or stable anatomy, vasculature and innervation. In infancy, the penis is very small and the surgeon cannot know how big the organ will grow or exactly where to do the cutting in order to obtain the desired cosmetic result. Because this is essentially a guess, too much tissue is sometimes removed; or indeed too little tissue, such that re-operation may be pursued.

    I have a 20 minute or so lecture on specifically the question of whether circumcision counts as a sexual harm for anyone interested, here: https://www.youtube.com/watch?v=SB-2aQoTQeA. You might also want to check out the paper, “Circumcision, Sexual Experience, and Harm” by a colleague and me: https://pennjil.com/brian-earp-robert-darby-circumcision-sexual-experience-and-harm-reply-to-stephen-r-munzers-secularization-anti-minority-sentiment-and-cultural-norms-in-the-german-circumcision-cont/

    Ethics. For a brief primer, I recommend the paper, “Medically Unnecessary Genital Cutting and the Rights of the Child,” an international consensus statement on the ethical issues published just last month, which I co-authored with about 90 mostly senior scholars in medicine, law, ethics, human rights, and other areas, with special expertise in genital cutting: https://www.tandfonline.com/doi/full/10.1080/15265161.2019.1643945

    We write, “Under most conditions, cutting any person’s genitals without their informed consent is a serious violation of their right to bodily integrity. As such, it is morally impermissible unless the person is nonautonomous (incapable of consent) and the cutting is medically necessary … a common understanding is that an intervention to alter a bodily state is medically necessary when (1) the bodily state poses a serious, time-sensitive threat to the person’s well-being, typically due to a functional impairment in an associated somatic process, and (2) the intervention, as performed without delay, is the least harmful feasible means of changing the bodily state to one that alleviates the threat. ‘Medically necessary’ is therefore different from ‘medically beneficial,’ a weaker standard, which requires only that the expected health-related benefits outweigh the expected health-related harms. The latter ratio is often contested as it depends on the specific weights assigned to the potential outcomes of the intervention, given, among other things, (a) the subjective value to the individual of the body parts that may be affected, (b) the individual’s tolerance for different kinds or degrees of risk to which those body parts may be exposed, and (c) any preferences the individual may have for alternative (e.g., less invasive or risky) means of pursuing the intended health-related benefits.”

    We argue that although the weaker, ‘medically beneficial’ standard may well be appropriate for certain interventions into the body, it is not appropriate for cutting or removing healthy tissue from the genitals of a nonconsenting person. If someone is capable of consenting to genital cutting but declines to do so, no type or degree of expected benefit, health-related or otherwise, can ethically justify the imposition of such cutting. If, by contrast, a person is not even capable of consenting due to a temporary lack of sufficient autonomy (e.g., an intoxicated adult or a young child), there are strong moral reasons in the absence of a relevant medical emergency to wait until the person acquires the capacity to make their own decision.

    The best argument for this view might be made by way of analogy. Consider a different example, that of labiaplasty. Labiaplasty is similar to circumcision in that it removes genital tissue that is not necessary for sexual enjoyment but which nevertheless has certain properties—sensitivity to touch, elasticity, independent manipulability, and so forth—that allow for particular subjective sensations, during sex or foreplay, for example, that many people value positively. It is also similar to circumcision in that the genital tissue it removes is often warm and moist and may trap bacteria, can become infected or even cancerous, may be injured or torn during sexual activity, and requires regular washing to maintain good hygiene.

    Removing the labia, therefore, likely does confer at least some statistical health benefits in that it reduces the surface area of genital tissue that is not essential for sexual function (in some narrow sense) but which may on occasion pose a problem of one kind or another for its owner. In addition, it may plausibly confer at least some psychological or social benefits for some women, insofar as they prefer the aesthetics of a vulva that has been subjected to labiaplasty, or if it helps them avoid negative judgments from potential sexual partners (however inappropriate such judgments may be). Indeed, the World Health Organization (WHO) includes such broader psychosocial factors in its definition of health, so perhaps these potential outcomes should be counted as “health benefits” as well.

    Now, let us assume for the sake of argument that performing labiaplasty in infancy is technically simpler, safer, and more cost effective—with a shorter healing time, and so on—than labiaplasty performed on a consenting adult. Would any of these considerations, alone or together, make non-voluntary neonatal labiaplasty permissible, either morally or legally, in Western societies? It seems unlikely. As I have argued elsewhere, even if health benefits of some kind or degree do one day become reliably associated with neonatal labiaplasty, it is almost certain that opponents of the practice (which includes the WHO, the United Nations, all Western democracies, and myself) would continue to see clear moral problems:

    First, they would argue that healthy tissue is valuable in-and-of-itself, so should be counted in the “harm” column simply by virtue of being damaged or removed. Second, they would point to non-surgical means of preventing or treating infections, and suggest that these should be favored over more invasive methods. And third, they would bring up the language of rights: a girl has a right to grow up with her genitals intact, they would say, and decide for herself at an age of understanding whether she would like to have parts of them cut into or cut off.

    The same arguments, I suggest, apply to male circumcision.

    Main reference

    Myers, A., & Earp, B. D. (in press). What is the best age to circumcise? A medical and ethical analysis. Bioethics, in press. Available from https://www.researchgate.net/publication/337720859_What_is_the_best_age_to_circumcise_A_medical_and_ethical_analysis (you have to request the text because I’m not allowed to publicly post it yet).

    Other hopefully useful writings from my colleagues and me discussing the ethics in light of both the science and normative considerations

    Earp, B. D. (2015). Female genital mutilation and male circumcision: toward an autonomy-based ethical framework. Medicolegal and Bioethics, 5(1), 89-104.

    Earp, B. D. (2016). Infant circumcision and adult penile sensitivity: implications for sexual experience. Trends in Urology & Men’s Health, 7(4), 17-21.

    Earp, B. D., & Darby, R. (2017). Circumcision, sexual experience, and harm. University of Pennsylvania Journal of International Law, 37(2 – online), 1-56.

    Earp, B. D. & Shaw, D. M. (2017). Cultural bias in American medicine: the case of infant male circumcision. Journal of Pediatric Ethics, 1(1), 8-26.

    Earp, B. D., & Steinfeld, R. (2018). Genital autonomy and sexual well-being. Current Sexual Health Reports, 10(1), 7-17.

    Frisch, M., & Earp, B. D. (2018). Circumcision of male infants and children as a public health measure in developed countries: a critical assessment of recent evidence. Global Public Health, 13(5), 626-641.

    • DeWitt says:

      Thank you for this post. I’m very glad someone with the necessary expertise decided to write something in favor of leaving infants uncircumcised on an article that is entirely in favor of iniant circumcision instead.

    • onyomi says:

      Thanks for the thorough, evenhanded comments!

    • NoRandomWalk says:

      Thank you for writing this.

    • cuke says:

      I’m so glad you took the time to come over here and write this. I found the article of yours linked to earlier upthread to be very helpful and bookmarked it to share around (as a psychotherapist who works with people in the transition to parenthood).

      There was some debate upthread as well about the proper roles of scientists, doctors, and philosophers in the realm of medical ethics. It looks like your training might span these realms, so if you’re inclined to say any more in this space, I’d love to hear your perspective about entities like the AAP weighing in on circumcision using a mix of health- and not-so-health-based arguments. Are there ethical guidelines for doctors around how they use their medical authority to communicate recommendations that are ethically/culturally controversial? If there are interesting articles around this topic, I’d love to know as well.

      • briandavidearp says:

        Thank you for such a nice comment. I’m not sure which essay you read, but my article, “Cultural Bias in American Medicine: The Case of Infant Male Circumcision” in the Journal of Pediatric Ethics (co-authored with David Shaw) addresses these exact kinds of questions:

        https://www.researchgate.net/publication/316527603_Cultural_bias_in_American_medicine_the_case_of_infant_male_circumcision

        Near the end, we argue as follows:

        In judging whether the conclusions of the AAP Task Force were biased or unbiased with respect to the medical evidence concerning newborn male circumcision, it is not especially informative to allude to the percentage of circumcised men in the population at large. Instead, it seems important to determine the attitudes of the members of the AAP Task Force themselves—i.e., the ones who reviewed the literature.

        Evidence of such attitudes may be found in the recent editorial by Andrew Freedman. Referring explicitly to extrascientific political considerations, Freedman stated that “protecting” the parental option to circumcise “was not an idle concern” in the minds of the AAP Task Force members “at a time when there are serious efforts in both the United States and Europe to ban the procedure outright.” The reference appears to be to a failed 2011 ballot initiative in San Francisco that sought to criminalize nontherapeutic circumcision before the age of 18, and to a 2012 Cologne court judgment—later overturned by the German legislature—finding that circumcision of male minors without a medical indication constitutes bodily assault.

        In this context, one may wonder whether protecting the parental option to circumcise should in fact have been an idle concern. As we understand it, the remit of the AAP Task Force was to evaluate, as dispassionately as possible, the empirical evidence concerning benefits and risks associated with newborn circumcision. Whether parents do or should have a right to authorize circumcision is an important and difficult question, and it is one that moral philosophers, bioethicists, legal theorists, and others are attempting to answer. But it seems fair suggest that it is not a question that should inform, much less consciously and deliberately inform, a scientific report on the medical consequences of newborn male circumcision.

        Liberal societies depend on scientific personnel to provide unbiased, apolitical analyses of “the facts” pertaining to their public deliberations. This goal is difficult to achieve in practice, as scientists are not immune from personal, cultural, and other biasing factors even in the best of circumstances, as we have seen. But it is widely held that they should do their best to neutralize such factors, using the most effective means available. Seemingly, a scientific committee that sees itself as engaged, however tangentially, in “protecting” a contested cultural or religious rite (an aim with respect to which a finding of net medical benefit would presumably be auspicious) has not done its best in this regard.

        A note on ethics—and equipoise

        We are not certain that it is appropriate for the AAP or any similar medical organization to opine on the ethics of circumcision: if the question is about benefits and risks, these should be documented clearly and thoroughly, based solely upon the empirical data. Moreover, if weights are to be assigned, these should be assigned by the person contemplating the surgery in light of his own preferences and values, as we have argued; a policy committee is not best qualified to make such judgments for others.

        If, however, an ethical discussion is to be included in a scientific report, it is desirable that more than one perspective be represented. In the context of a debate that is as polarized as the one on circumcision, it is notable that the single bioethicist appointed to the AAP Task Force, Dr. Douglas Diekema, had already made his views on the subject clear, previously arguing in favor of the permissibility not only of male forms, but also certain female forms of ritualized genital cutting, despite near-universal condemnation of the latter.

        This sole appointment is notable because the view that neither male nor female children deserve absolute protection from having their genitals cut for nontherapeutic reasons is an outlier position among policy experts. Moreover, the “harm principle” promoted by Diekema, which explicitly favors expansive parental rights over the advancement of children’s best interests, is similarly contentious. It is reasonable to think that a committee with as much influence as the AAP Task Force would strive to include a diversity of voices in its ethical discussions.

        There are legitimate arguments to be made that newborn male circumcision should be considered morally and/or legally acceptable. One could even argue that religious circumcision in particular should be tolerated even if it is a net (medical) harm, since there are numerous factors at play in such determinations apart from risk-benefit assessments. However, the moral and legal status of nontherapeutic genital altering procedures have become increasingly controversial in the past few decades, with a growing contingent of scholars maintaining that all such procedures performed on children (male, female, and intersex) should be discouraged if not forbidden.

        Therefore, to achieve a properly balanced consideration of the opposing viewpoints, future committees in this area should consider appointing at least two ethicists representing the range of current thinking on the issue. The dialectic between them, it is hoped, would yield a more nuanced and comprehensive ethical discussion than was evidenced in the 2012 AAP documents. As J. Steven Svoboda and Robert Van Howe have stated, these documents

        fail to mention foundational principles from biomedical ethics. Seemingly, such notions as respect for autonomy, the child’s right to an open future, and the normally high bar set for surgical interventions on minors would be at least worth alluding to in a serious discussion of the moral permissibility of male circumcision. Yet the AAP’s repeated, unsupported, alternative suggestion that, “In most situations, parents are granted wide latitude in terms of the decisions they make on behalf of their children” constitutes their entire ethical argument.

        Svoboda and Van Howe overstate their case, here, because the AAP Task Force does mention that parents and physicians have an “ethical duty to the child to attempt to secure the child’s best interests and well-being.” However, the immediate next move of the Task Force is to emphasize that reasonable people disagree as to what is, in fact, in the child’s best interests, leading them to the “alternative suggestion” mentioned by Svoboda and Van Howe. In other words, given that people have different judgements about what best promotes a child’s well-being, parents should normally be allowed to take or authorize any action whatsoever toward their child, the Task Force suggests, unless it is “clearly contrary to the best interests of the child or places the child’s health, well-being, or life at significant risk of serious harm.”

        A problem with this view is that, just as reasonable people disagree about what is in a child’s best interests, reasonable people also disagree about what is clearly contrary to a child’s best interests, and about what places the child’s health, etc., at “significant risk of serious harm.” In fact, removing part of a child’s genitals in the absence of a clear medical need is just the sort of thing that many reasonable people do regard as a serious harm, regardless of whether there may also be certain modest health benefits that follow from such removal. So what does this analysis suggest about the limits, if any, there should be on parental behavior? If reasonable people can disagree not only about “best interests” but also about “serious harm,” then a practical implication of the AAP’s proposal seems to be that parental decision-making should remain essentially unfettered.

        No one can deny that, “in most situations,” parents are (and should be) permitted to make decisions on behalf of their children (see Box 3). But in the context of Western medicine at least, one could also argue that nontherapeutic genital surgery is not “most situations.” In other words, while it is true that parents generally have “wide latitude” in bringing up their children as they see fit, it is also true that societies justifiably place certain restrictions on parental actions, particularly when it comes to irreversible body modifications that their children may later rationally regard as a harm.

        To illustrate, in some jurisdictions, tattooing a child’s body is not permitted, even when the parents believe the tattoo is the child’s best interests. With respect to the United Kingdom, for instance, as James Chegwidden notes, “the common law is very cautious before treating [even] children’s consent as justifying any non-therapeutic body alteration.” Indeed, in British Parliamentary debates regarding a proposed ban on tattooing prior to age 18, concerns were raised that

        apply almost identically to the arguments voiced about circumcision, namely: the existence of persons who later regret having the procedure done; the difficulty of reversing the procedure; the danger of infections and other complications arising from the tattooing procedure; […] the embarrassment felt by those tattooed who later regret it; the unhygienic conditions in which some tattooing is performed [and so on].

        Failing to apply this reasoning consistently leads to peculiar results. For instance, while parents would not be allowed to tattoo their son’s foreskin for nontherapeutic reasons in such jurisdictions, they would be allowed to have his foreskin completely removed for nontherapeutic reasons, and then tattooed. This example provides further evidence that newborn male circumcision occupies an anomalous position in Western (medical) culture.

        More relevant, however, as we have already noted, is the practice of nontherapeutic FGC. In Western societies, including the United States, parents may not cut into, much less excise, any part of a female child’s genitalia when it is deemed medically unnecessary to do so. Crucially, this is the case even when (a) the cutting is less extensive, risky, or harmful than male circumcision, (b) the parents sincerely believe it is required by their religion, and (c) it is likely to confer significant social benefit on the child, due to the prevailing beliefs, attitudes, and expectations of the community in which she is being raised.

        In order to determine whether any particular nontherapeutic alteration of a child’s body is ethically and perhaps also legally acceptable, therefore, it is not enough to invoke a vague conception of “serious harm” (such that, for any action X, an interested party could plausibly argue that it is “not harmful enough” to warrant state interference), nor to refer to the “wide latitude” that is typically granted to parents. Instead, it is necessary to triangulate between analogous cases to determine where the limits lie.

        Conclusion

        As Shaw has argued, a near-exclusive focus in the medical literature on potential biases stemming from financial conflicts of interest “has tended to obscure the fact that other biasing factors can seriously compromise an author’s impartiality and objectivity.” In the present context, we have argued that one such potentially biasing factor is whether one has been circumcised oneself, or has circumcised his or her son. Because circumcision is irreversible, there is likely to be a strong motive among such persons to reach the conclusion that it is desirable on balance to be circumcised. For if it is not desirable on balance, there are few, if any, options for “undoing” what has already been done.

        Moreover, having a personal or political stake in circumcision, whether on religious or other grounds, could also play a biasing role. While individual Task Force members should feel free to lobby for legal or other protections for nontherapeutic circumcision as private citizens, they should not allow such political ends to enter into their evaluations of the science. Moreover, a concerted effort should be made to balance out whatever political, moral, or other normative viewpoints there are among committee members, by appointing not only proponents of circumcision, but also critics. More generally, whenever professional medical or ethical opinion is polarized, qualified representatives of both poles should be included in the relevant scientific and policy discussions.

        • cuke says:

          Thanks, very helpful.

          This particularly: “Whether parents do or should have a right to authorize circumcision is an important and difficult question, and it is one that moral philosophers, bioethicists, legal theorists, and others are attempting to answer. But it seems fair suggest that it is not a question that should inform, much less consciously and deliberately inform, a scientific report on the medical consequences of newborn male circumcision.”

          The only other instance I can think of in medicine where we preventatively remove healthy tissue in people as a matter of routine medical recommendation is wisdom teeth. Perhaps there are other examples? Though in the instance of wisdom teeth, patients are still evaluated on an individual basis and most are near adulthood at the time of extraction so there is at least some potential for consent, even if many dentists don’t do a great job of seeking full informed consent from their teenage patients.

    • Steven says:

      Brilliant write-up. I am glad to see an expert weighing in.

      I love the fact that your comment is over twice the length of the original article! It actually has the time and space to delve into the questions that need to be asked, and to analyse the studies properly.

    • medvssa says:

      Thanks for posting this
      Scott, I think you should link to this important comment in the article, as it’s otherwise buried at the bottom.

    • mantelwriters says:

      Brian, you are one of the world’s foremost experts on the ethics of circumcision and you seem to have a comprehensive understanding of the various perspectives and variables around the issue. Clearly your position is grounded in a secular autonomy-based ethical framework from which you privilege consent and the right to bodily integrity and self-determination (particularly in the case of an irreversible procedure such as circumcision). I think this will be viewed as a common sense position by most secular rationalists here. Most of your comments here relate to the medical cost-benefit aspects of the procedure and you do not seem to believe that it is medically necessary, on balance, to pre-emptively circumcise infants who cannot give their consent. However, given the relatively harmless nature of the procedure, I am inclined to believe that some weight should be given to the importance of cultural identity, kinship connections and certain aesthetic values in considering the ethics of circumcision. I wonder how much weight, if any, you would assign to these considerations?

      As I’m sure you’re aware, there are cultural and religious imperatives among Jewish people that their sons be circumcised on the 8th day and among Nigerians that they be circumcised on the 7th day, for two examples. How much consideration should we give to the collective wellbeing of those rather large communities in sustaining their culturally-significant customary practices of neonatal circumcision (in terms of their wish to follow received traditions, honour perceived covenants with God, maintain a connection with ancestral groups, and embody certain aesthetic values around the shape, smoothness, and sense of hygiene and cleanliness of their genitals)? As you are an ethicist, I am very much interested in your views about the social, cultural and religious imperatives of circumcision.

  72. mantelwriters says:

    I think the ethical questions around circumcision are more interesting than the health benefits (because the health benefits to male circumcision—and possibly even some forms of neonatal female cutting— seem to be happy accidents). Central to the circumcision debate is the problem of autonomy / independence vs community / interdependence and the different views we hold about what is physically and psychologically ‘necessary’ and culturally ‘legitimate’. I think that may be worth exploring further. Of course, the debate is also colored by strong emotions around disgust and notions of ‘mutilation’ vs ‘enhancement’ without an understanding of the layers of context behind those intuitions.

    From the POV of an Orthodox Jew, neonatal male circumcision is necessary because it represents a longstanding covenant between the Jewish people and their God. A grown Orthodox Jewish man may approve of his circumcised penis—not just for the (apparently) small but cumulative health benefits—but for the evidence of his parents’ piety and willingness to obey God’s command to Abraham. He may also take pride in the circumcision because it is a sign of sacrifice (loss of foreskin) to signal his solidarity with his persecuted ancestors. There are similar (Haidtian) community-based and purity-based motivations behind the practices of some Maori groups who tattoo their children’s faces before they can meaningfully consent. (To my mind, there are even some similarities between circumcision and the orthodontic work imposed on children around the world—which involves some pain and discomfort for children and can sometimes go wrong—all for the sake of a socially pleasing smile).

    From the POV of a secular, cosmopolitan liberal man, neonatal male circumcision may be equated with female genital cutting (or ‘mutilation’). As such circumcision is an unnecessary ancient (barbaric) practice that has no place in a civilised society because it removes a part of someone’s body without their consent. From that POV, the only way to ensure a fair society in a multicultural world is to ensure that autonomy-based rights are privileged over received moral traditions.

    From one perspective, ‘physical integrity’ is given at birth and from the other perspective physical integrity is something that is earned.

    From one perspective, mental health entails feeling a strong sense of kinship and belonging and approval of those around you. From another perspective, mental health entails self-determination.

    From one perspective, physical beauty (for both men and women) is associated with smooth genitals without any fleshy encumbrances and a ‘clean’ and hygienic feeling. From another perspective, physical beauty is associated with embracing who you are (remaining as close as possible to the way nature intended).

    From one perspective, an Intactivist would feel great regret that a piece of their body was removed without their consent. They would never feel ‘whole’. From another perspective, (perhaps a Kantian of Muslim background) there would be a sense of regret at NOT having being circumcised at birth (for who would choose to have it done later?) for their bits would not look like those of their kin and ancestors.

    I think one reason that male circumcision is largely tolerated and yet female genital cutting (or ‘mutilation’) is so vilified (even though there are differences in forms of FGC just as there are clear differences between sanitised neonatal circumcision and outback penile sub-incision) may be that Jewish and Muslim men have more political power around the world than African women. There are only a few African women who have spoken up about the value they place on the process (initiations to adulthood / womanhood which don’t apply to this debate about neonatal circumcision, labia cutting or trimming) and the aesthetic outcome. Fuambai Ahmadu is one such woman who has spoken out about the importance of female genital cutting to her.

    To tease these issues out further, perhaps an interesting future adversarial collaboration might be between someone like Ahmadu who believes there is a place for FGC and a secular policy maker (or medical practitioner) who believes that male and female genital circumcision is mutilation and child abuse. Perhaps a more realistic (and productive) wish would be a debate between the anthropologists / ethicists Richard Shweder (one of Haidt’s teachers) and Brian Earp (who has commented above) because they both seem to have given careful consideration to the ethical issues around male circumcision and female genital cutting, yet arrive at different conclusions and hold opposing views.

    • anon_ 412 says:

      I absolutely LOATHE that I’ve been circumcised. Seriously considered suicide because of it. Circumcision is NOT harmless, it causes a significant loss of function (see https://evidencebasedbirth.com/evidence-and-ethics-on-circumcision/).

      You can talk all you want about “cultural values”, but at the end of the day, what do you have to say to me and the many others like me, who VERY DEEPLY regret what’s been done to us? Why don’t our rights mean anything to you?

  73. brownbat says:

    I think this is a very well organized survey of the lit. Appears very comprehensive — I attempted a research dive on this topic a few years ago and learned several new things here. Going from strongest effects to weakest made the piece easy to follow.

    I caught a few relatively minor opportunities for improved clarity or comprehensiveness:

    – The rate of UTIs is provided, with the note that some can be severe. Since it might be argued that mild self-limiting infections aren’t a significant concern, what’s the incidence of severe UTIs?

    “The benefits of infant circumcision appear to outweigh the risks and harms.” This was unexpected in the ethics section, I think it would be more compelling if it was a closing transition from the medical section.

    To that end, it would have been useful to see a roundup summarizing expected impacts at the end of the medical section — among a fictional cohort of 10,000, if circumcised, we might expect x fewer severe UTIs, y fewer cases of various STIs, and z additional (specific complication from surgery here).

    (The complications might be so broad that you might just have to pick whatever you consider to be the most salient ones.)

    Possibly out of scope, but other possible directions to take the benefit / harm comparison:
    – STI prevalence is not uniformly distributed, and from the Korean study it sounds like complications aren’t uniformly distributed, so there might be an outcome where the benefits of circumcision outweigh the harms for some groups and localities, but not others.

    – STI severity is mediated by medical progress, so it might be the case that circumcision could be currently beneficial but with a downward trajectory heading the other way, contingent on specific medical or social changes like widespread HPV vaccination.

    The ethics section could have been strengthened through external references. I know ethics wouldn’t yield scientific studies, so it wouldn’t be really comparable, but there still has to be some professional academic lit on this topic worth a nod. A cursory google points to the Stanford Encyclopedia of Philosophy’s article on the ethics of parenting, which has at least a reference to Benatar and Benatar in 2003, “Between Prophylaxis and Child Abuse” in the American Journal of Bioethics. From the abstract, it looks like it might have been worth a read, possibly would have given you a good quote to mine or two.

    It’s always easier to spot areas for improvement than to draft the thing in the first place, so don’t take any of this too harshly, really great job overall.

  74. fwiffo says:

    What if two advocates of a position sneakily decided to enter into an adversarial collaboration, and then presented a one-sided view of the topic, which then shifted a lot of people’s prior because of the ACC’s imprimatur of unbiasedness?