Circumstitions

Intersecting as it does sex, religion, blood, medicine and masculinity, circumcision is a subject that is hard to discuss rationally.

The male human foreskin or prepuce is a remarkable structure. Far from being “just a flap of skin,” it amounts to about 100 cm2 (15 sq in) or about half the outer surface of the adult penis. It is rich in specialised sensory nerves, and has a unique way of unrolling out over itself to uncover the glans and cover the shaft during intercourse. Men who have involuntarily lost their foreskins in adulthood compare the effect with going colour-blind.

The more remarkable, then, that human history is rife with crazes for cutting the foreskin off. Three cultures originated male genital cutting: in Africa, Australia and the Pacific. The African custom seems to have been taken through Egypt to the Middle East and then to Europe, and in the 19th century in England and the US it was medicalised with the aim of preventing masturbation, becoming widespread throughout the English-speaking world. It continues to be claimed as a panacea for whatever ailment people most fear at the moment.

Christchurch skeptic Jay Mann wrote (NZ Skeptic 84), “One thing that activates my BS-meter is a miracle treatment with too many claims.” Mine too. I started collecting bad reasons to circumcise (“circumstitions”) in 1998. There seemed too many to be reasonable, and I thought a complete list of as many as 30 would make Jay’s point. I now have 340 reasons, in 30 classes, and they show no sign of stopping-see Table 1. The classes are so bafflingly varied that something else has to be going on.

Aesthetic	Instructive	Revenge
Anti-sexual	Irrational	Reward
Cleanliness	Medical	Sexual
Concealment	Mistake	Status
Conformity	Non-conformity	Submission
Control	Pity	Symbolic
Convenience	Pre-emptive	Sympathetic magic
Financial	Prudery
Iatrogenic	Punitive	To benefit someone else
Ignorance	Religious
Initiation	Reproductive	Vague
Table 1. Reasons given for circumcision (And yes, some of those do contradict each other).

Skeptics will, I hope, dismiss out of hand the many obviously irrational reasons for circumcising such as ‘tradition’ and ‘to look like his father’ (conformity), but medicine has the seductive respectability of science.

Medical reasons for circumcision include the prevention or cure of the conditions listed in Table 2.

Alcoholism	Headaches	Penile cancer
Arthritic hips	Hernia	Plague
Asthma	HIV	Philmosis
Balanitis	HPV	Posthitis
Bedwetting	Hydrocephaly	Prostate cancer
Blindness	Hydrocoele	Rectal prolapse
Boils	Hypertension	Rheumatism
Cervical cancer	Insanity	Schistosoma
Chicken pox	Kidney disease	Spinal curvature
Epididymitis	Kleptomania	Stomach infection
Epilepsy	Leprosy	Tuberculosis
Gallstones	Moral depravity	Urinary tract infections
Gout	Paraphimosis	Yeast infections
Table 2. Medical conditions for which circumcision has been claimed as a cure.

Some of those are obviously bogus-the others, less obviously so. In each case the science is non-existent, flawed or misinterpreted, but these few look plausible:

STDs: A 2006 study in Christchurch by Fergusson et al, gained headlines around the world before Fergusson admitted his result was anomalous and it would take at least 20 circumcisions to prevent one minor STD. (He found no major STDs.) His retraction was not widely reported.

Urinary Tract Infection: It would take more than 170 circumcisions to prevent one boy contracting a UTI, according to To et al (1998). The rate among girls is several times that of boys. The major study (by US army paediatrician Thomas Wiswell) showing a protective effect:

• was entirely based on boys born in military hospitals
• used different means of collecting urine samples in the two groups
• assumed that any bacteria cultured from a sample represented a UTI
• neglected the effect of premature birth postponing or cancelling circumcision, and leading to intensive care and catheterisation-which causes UTIs.

Penile cancer: one of the rarest of cancers (with a lifetime incidence of less than one in 600, less common than male breast cancer), generally occurs only in old men. The rate is higher in the circumcised US than non-circumcising Denmark.

Cervical cancer (in partners): The main study on which this claim relies (Castellsagué et al, 2002), pooled data from five different countries. Almost all the circumcised men were in the Philippines, most of the intact men in the other four countries (Brazil, Colombia, Spain and Thailand). Naturally, there are many other demographic differences between those countries. The evidence boiled down to

• 1 circumcised man in Brazil,
• 1 in Colombia and
• 3 in Spain who didn’t have HPV,
• nobody in Thailand, and
• 1 intact man in the Philippines who did have HPV –
• a total of 6 men.

After all that, it referred only to Human Papilloma Virus (HPV) (of which there are a number of varieties, only some of which are linked to cervical cancer), not to cervical cancer itself.

HIV

It was inevitable that HIV/AIDs would fall under circumcision’s spell. It would take hundreds or even thousands of circumcisions to prevent one transmission of HIV in a country with a low incidence like New Zealand, if the three African random controlled trials (Auvert et al, 2005; Bailey et al, 2007; Gray et al, 2007) were correct. In fact, they have multiple flaws; for example:

• they were not double-blinded or placebo-controlled, and they were conducted by circumcision enthusiasts, at least one of whom had campaigned for mass circumcision before the trials were ever held;
• the men were not a random sample of the population, but volunteers given a substantial reward;
• the circumcised experimental groups were given safe-sex advice that the intact control groups were not;
• the trials were cut short, so we will never know what the long-term effect will be, and they can probably never be replicated;
• at least 380 (10 percent) of the circumcised men dropped out of the trials-those who found they had HIV would feel let down and be more likely to do so. Only a few such men would reduce the results to non-significance;
• the studies’ significance would be diluted by sex with men and non-sexual transmission, believed to amount to about 40 percent of transmission in Africa because of “needle men”-amateurs who offer injections for any and every complaint, using the same needle;
• the non-circumcised control group in Uganda got less HIV than the circumcised experimental group in Kenya, probably because Uganda had campaigns against promiscuity (“zero grazing”), while the Kenyans were mainly fishermen on Lake Victoria with ‘girlfriends’ in every port.

Earlier, cross-sectional studies were confounded by such factors as religion-the circumcised men were largely Muslim, with different sexual customs and prohibitions.

In spite of this, an invitation-only meeting in Montreux, Switzerland (whose participants have not been publicly listed but seem to have included those same circumcision enthusiasts) has mobilised WHO and UNAIDS to “roll out” mass-circumcision campaigns in Africa-using a manual that was in preparation before the trials began.

Risks and costs

A baby can afford to lose only about two tablespoons of blood before he needs a transfusion. Modern absorbent nappies such as Treasures can easily conceal this much blood loss. Circumcision presents a real risk of MRSA or VRE infection. A recent death in Ontario was due to the device Prof Sitaleki Finau of Massey University calls “non-surgical” blocking the baby’s urethra. Ablation of part or all of the penis can occur-in the most famous case, Bruce/Brenda/David Reimer of Winnipeg, Canada, was unsuccessfully reassigned as female, and eventually committed suicide. There are many lesser complications and adverse outcomes that may not be noticed until the victim reaches adulthood. The pain reaction is measurable for months afterwards; for decades, babies were circumcised without anaesthetic.

Sexuality

It should be self-evident that cutting part of the penis off has a detrimental effect on sexuality-this was known for centuries before circumcision became widespread. Incredibly, the most widely reported studies of penile sensation (Masters & Johnson, 1966; Payne et al, 2007), both claiming circumcision had no effect, didn’t measure the foreskin. One that did (Sorrells et al, 2007) found a striking difference. Circumcised men insist that “if I was any more sensitive, I’d have a heart attack” (a claim that itself suggests something is amiss) yet intact men do not fill our cardiac wards. Such a claim mistakes quantity for quality. The answer demands closer study of the neurology.

Psychology

How, you may wonder, can a practice so bizarre, abhorrent even, have become so popular? A good question, not yet fully answered, but we can look at power and control, sympathetic magic, a multi-faceted memeplex that has a momentum of its own, money, and men’s refusal to admit that they have lost anything, but rather a determination to ensure that nobody may have more penis than they do. Some circumcision enthusiasts (who call themselves ‘circumsexuals’) have an unwholesome interest in the procedure itself. Intersecting as it does sex, religion, blood, medicine and masculinity, circumcision is a subject it is hard to discuss rationally. Much scientific writing on the subject is tainted by these biases.

Human rights

Many men are so outraged that part of their penis was cut off, that they go to considerable trouble to replace it. (A good aesthetic effect can be achieved by slowly encouraging the skin to grow by applying tension-not ‘stretching’-but the sensory effect can never fully return. Surgical means are not advised.)

It should be obvious that cutting an integral part of a healthy baby’s body off is a human rights violation. It is obvious when the baby is a girl, and an amendment to the Crimes Act outlaws female genital cutting specifically and totally, regardless of degree, under all circumstances (except medical need), with no exception for religion or culture, or even the adult woman’s own consent.

Male vs female genital cutting

The objection is often vehemently raised that there is no comparison between male and female genital cutting (MGC, FGC). But both cover a range of practices, and the mildest of FGC is milder than the most severe of MGC. MGC may be carried out under conditions similar to FGC (with nearly 40 deaths a year in Eastern Cape Province alone). As ethical issues, as human rights violations and as invasions of a person’s most personal space, they are equivalent.

Recent history

Infant circumcision became near-universal in New Zealand by the 1950s. (It is not true that many men had to be circumcised in the North African desert campaign of World War II, though that reason was commonly given. I am grateful to Manfred Rommel for taking the trouble to enquire of his father’s surviving troops.) It declined to near-zero through the rest of the century, the main exceptions being Pacific Islanders, Muslims and Jews. This apparently happened top-down, National Women’s Hospital refusing to offer circumcision at public expense from the day it opened in 1962. In the mid 1970s, it became policy not to offer it to new parents (the ‘sleeping dogs’ policy), and some time during that decade it was taken off Social Security. The result is that most New Zealand men over 35 are circumcised, most under that age are not. (In England, the probability goes up with class, in the US, as you go north and east.)

In August 2007, Victorian public hospitals banned the operation, South Australia announced a review of its policy and the Children’s Commissioner for Tasmania called for the female genital cutting ban to be made gender-neutral.

Yet in October 2007, Prof Finau called for infant male genital cutting to be offered in New Zealand public hospitals again.

The movement to oppose non-consensual (male) genital cutting (Intactivism) is small and unpopular, and generally regarded as eccentric, yet we know we are the rational ones.

List of references available from the editor.