Science moves on bodies of evidence

I’ve long made the point that science moves on bodies of evidence, not individual studies. If you don’t have repeatable data, then you don’t have much of anything. This is why the media is frequently so bad when it comes to reporting on recent studies; they report (or at least imply) individual study results as conclusions that are being made by the scientific community at-large. The truth is usually more like, one group of researchers found some interesting results.

And with that in mind, I turn to one of my favorite topics in science, circumcision. My numerous posts are easily searchable, so I won’t bother to link them, but for those who are unfamiliar with my stance, let me be clear: I am hugely in favor of circumcision because the science is in – circumcision saves lives. Furthermore, there is a very clear body of evidence that circumcision does not decrease sensitivity or sensation. In fact, a recent study found just the opposite:

Of 454 circumcised men, 362 (80%) returned for a follow-up visit 6 to 24 months after VMMC (voluntary medical male circumcision). Almost all (98%) were satisfied with the outcome of their VMMC; most (95%) reported that their female partners were satisfied with their circumcision. Two thirds (67%) reported enjoying sex more after VMMC and most were very satisfied or somewhat satisfied (94%) with sexual intercourse after VMMC. Sexual function improved and reported sex-induced coital injuries decreased significantly in most men after VMMC.

For someone like me who is greatly in favor of circumcision, this is great news. While it is only a survey study rather than a research study, it still provides evidence that circumcision is even better than the scientific community thought. However, that’s just not how science moves. Find me another several dozen studies like this using a variety of methods, and if they show a trend that confirms the results here, then I’ll start believing it. But as things stand now? I can’t make the leap. There is a standing body of evidence that says circumcision doesn’t affect sensitivity or sensation one way or the other; for every study that reports positive results, there’s one that reports negative results (and more often, studies report mixed or push results).

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Uganda adopts circumcision, finds science works

This is no real surprise:

The growing uptake of medical male circumcision by men in the Rakai district of Uganda is leading to a substantial reduction in HIV incidence among men in one of the districts of the country worst affected by HIV, Xiangrong Kong of Johns Hopkins Bloomberg School of Public Health told the Conference on Retroviruses and Opportunistic Infections (CROI 2015) in Seattle, USA, on Thursday…

The study found that circumcision coverage in non-Muslim men increased from 9% during the Rakai circumcision study to 26% by 2011, four years after the trial concluded. Every 10% increase in circumcision coverage was associated with a 12% reduction in HIV incidence (0.88, 95% confidence interval 0.80-0.96).

HIV incidence reduction in women lags behind but is expected to catch up in coming years.

We’ve known for the better part of the past decade that circumcision literally saves lives by acting as a high efficacy vaccine that reduces female-to-male HIV transmission by 60% (which is better than the flu vaccine most years). That we’re seeing the positive results of implementing it as a policy isn’t surprising. Science just works.

Why circumcision is a very good thing

I’ve written numerous posts about circumcision and its benefits, but I want to write one more big one. My goal here is to gather together all the relevant information to the debate in one place. Certain myths need to be dispelled in some places while the details of arguments need to be laid out with ridiculous clarity; the anti-circumcision crowd is as stubborn as young Earth creationists. As such, this post isn’t so much directed towards the entrenched anti-circumcision folk as it is towards the people on the fence. Perhaps there are a few people out there who have simply bought into easy arguments, and so their commitment to their position can be swayed. I would equate these people with the occasional church patron that grows up learning the Universe is 6,000 years old, only to later shed that false belief when engaged on the matter. I hope I’m able to adequately mount a defense of circumcision and change the minds of any such people who end up reading this post.

There are several topics that should be addressed when discussing circumcision. Safety, efficacy, and ethics are the broad categories, and each one contains its share of details. Let’s start with safety.

Safety:

As with any surgery, complications are possible. The most common complication due to circumcision is minor bleeding, which can be fixed with a little bit of gauze. Infections occasionally happen, but they’re rare. Circumcision should always be done under sterile conditions to maintain this rarity. (That means the Rabbis and other non-medical professionals out there who do these things need to be stopped.)

Pain and Trauma:

A favorite of the anti-circumcision crowd is to find awful looking restraining devices doctors use to keep infants steady. Aside from the fact that those devices aren’t the iron maidens people make them out to be, circumcision needn’t be painful in the least. Any search will find a mix of estimates for how frequently anesthesia is used during circumcisions, but it is certainly used a majority of the time, and its use is always increasing. Any parent worried about the pain their baby may feel can simply request anesthesia be used. This 100% addresses any pain argument the anti-circumcision crowd wants to raise. Indeed, it also addresses any trauma argument they wish to raise, but it isn’t necessary for that purpose. Trauma is something which has lasting physical or psychological damage. Since no infant can possibly remember being circumcised, there’s no way any amount of pain could be traumatic here. Moreover, the pain of being squeezed through a vaginal canal just days earlier is clearly much more significant than any minor medical procedure.

Nerve Ending Hypothesis:

There is a popular hypothesis that because the foreskin has 10,000 to 20,000 nerve endings, any removal of it must affect sensitivity. It makes sense and it’s worth investigating. Unfortunately, it’s that investigation aspect that many in the anti-circumcision crowd don’t like; for many, the hypothesis is conclusive. Occasionally, though, they may point to a study or two they incidentally find – so long as it supports their beliefs, of course. These studies (which are usually actually just subjective surveys) sometimes indicate decreased sensitivity in circumcised men. Other times, they show just the opposite. (The anti-circumcision crowd ignores those.) Mostly, though, they show statistically insignificant differences. Moreover, the better studies and meta-analyses out there show the same wash. Since science operates on bodies of evidence rather than individual studies – if you can’t repeat your data, it’s bullshit – the correct conclusion here is that not only is there no body of evidence that circumcision decreases sensitivity, but there is actually an active body of evidence which shows it has no effect.

Efficacy:

This is where the majority of this debate centers. It isn’t enough to look at all the evidence and conclude that circumcision is low-risk, painless, non-traumatic, and inconsequential in sexual sensitivity and performance. That’s all great, but none of that adds up to a reason to circumcise someone, much less to implement it as a public health policy. What we need is data which show circumcision offers some sort of benefit. You’ll never guess what we’ve had for the better part of a decade.

Three randomized control studies were undertaken and completed between 2005 and 2007. These studies looked at the effect of circumcision on HIV transmission rates from women to men during heterosexual intercourse. (Prior to these studies there was a body of observational studies which indicated a likely link between circumcision and HIV, but it wasn’t nearly concrete enough to enact any type of policy.) These studies concluded that circumcision significantly reduces HIV transmission in the aforementioned context; one study went so far as to compare the reduction to what would be achieved by “a vaccine of high efficacy”. Between the studies, the relative risk reduction was 60%.

Relative versus Absolute

For some time I had an anti-circumcision troll around here. He enjoyed raising the issue of relative risk versus absolute risk. I’m not sure he understood the difference, though. Whereas the relative risk reduction for circumcised males was found to be 60%, the absolute risk reduction is between 1.3% and 1.8%. Choosing the latter of these numbers is a good way to muddle the discussion. Here’s what these numbers mean.

Relative risk reduction is how much a given treatment, behavior, or characteristic reduces a given risk in one group versus another. This is the number that matters most of the time in lay terms. Absolute risk reduction, on the other hand, looks at an entire population and takes into account its susceptibility to some given condition. For instance, most people aren’t going to get the flu. It doesn’t matter whether a person has the vaccine or not. Odds are low that he or she will catch anything. That’s why anti-vaccine quacks love to use absolute numbers. The flu vaccine is generally somewhere near 60% effective, but absolute numbers are closer to 1.5%. That isn’t an argument against getting vaccinated, though.

Problems with the Studies

The three aforementioned studies were robust and have been largely accepted by the scientific community. The WHO, UNAIDS, the CDC, the Bill and Melinda Gates Foundation, and a dozen and a half African health ministries have all embraced their results. Of course, that isn’t going to stop the anti-circumcision crowd from coming up with something to question. Most commonly, the issues raised are non-issues. For instance, I’ve frequently seen the point raised that condoms are more effective. This is like when a creationist tries to argue against evolution by talking about the Big Bang. It just isn’t on topic. Other issues include the region where the studies took place, the early termination of the studies, and control and intervention groups being treated differently. Let’s start with where these studies took place.

It should first be noted that, as I mentioned earlier, there is a large body of observational studies on the effectiveness of circumcision in HIV transmission reduction. This body is global; what it indicated panned out in these trials. Second, Africa is massive. Uganda and Kenya are neighbors, but South Africa isn’t even close. These places have commonalities, but they are also significantly different in a host of aspects, including culturally. Repeated results across a wide swath of area cannot be simply dismissed out of hand: the limited region of each individual study could be a confounding factor, but when taken as a whole, the studies necessarily reduce any potential confounding factor due to regional effect.

Each study was halted early on ethical grounds. The results were so overwhelming, the monitoring boards for each study had no choice but to put an end to the trials and recommend that all the uncircumcised men be circumcised. Regardless, the studies still all lasted between about a year and a half and two years. Potential bias as a result of these abrupt endings was taken into account. From the Kenya study:

Because the Data and Safety Monitoring Board recommended to stop the trial after the intermediate analysis, it was not possible to follow all the participants as initially planned, and, as a consequence, only those participants recruited at the beginning had a full follow-up. This potential bias was taken into account by adjusting the analysis for the recruitment period; such an adjustment cannot fully account for the confounding effect associated with partial follow-up. When restricting the analysis to those participants who had a full follow-up, the intervention had an effect that was similar in size and significance, suggesting that this potential bias had a negligible impact.

Another common complaint is that a large number of participant follow-ups were lost due to the early terminations. The effect was likely negligible since the numbers actually weren’t that significant for these type of studies, plus many of the follow-ups were actually lost for reasons unrelated to HIV infection (such as moving from the area). Knowing this is one of the benefits of having actually read the studies rather than agenda-driven websites.

Finally, I frequently come across Internet comments that declare the control and intervention group were treated differently. The claim is that the intervention (circumcised) group was given education, condoms, and counseling over and above what the control group was given. This is simply a lie. I’m not sure of its origin, but I’ve seen it enough that I feel it deserves to be killed. The groups were given and/or offered consistent treatment. The only reason to say otherwise is for the same reason Lyndon Johnson told one of his aides to spread the story that one of his opponents fornicated with pigs. He knew it wasn’t true, but if he could make the other guy deny it, he would be giving it credence by simply addressing it. As usual, I’m willing to forgo the public perception in favor of assuming a literate readership.

How It Works

The evidence is in when it comes to circumcision, but how it works is still up for question. One hypothesis says that the foreskin offers a relatively damp environment that is friendly to various pathogens. Another hypothesis says that Langerhans cells are a target of HIV, causing them to act as a vector. Since the relatively thin foreskin has these cells, that means there is an increased surface area and number of these cells where HIV can attach.

Other Benefits

Circumcision has been found to have a host of other health benefits (.pdf). UTI’s are decreased among newborns, penile cancers are reduced, general infections are reduced, and HPV is 30% less prevalent. One study from 1954 to 1997 that looked at cases of invasive penile cancer found that 87 out of 89 (98%) of the men were uncircumcised. Other studies have found a 30% decrease in contracting herpes.

Developed World Efficacy

The CDC has recently come out as endorsing circumcision has a healthy decision for parents to make. It’s a one time cost for a procedure with a low incidence rate of what are only minor complications anyway. The child feels no pain, there is no trauma, sensation isn’t affected at sexual maturation, and a host of diseases are reduced. If the CDC didn’t stop short of recommending circumcision as a health policy for political reasons, then they only did it because STD’s are not an epidemic in the United States. But, then, neither is the flu.

Condoms and Hygiene

The anti-circumcision crusader may get to this point and say, “Fine, even if everything to this point is true, it’s still undeniable that condoms, education, and basic hygiene can best take care of the major health issues raised here where Africa is concerned.” And that’s fair enough. Condoms are 97-99% effective at preventing sexual transmitted diseases. Retracting the foreskin and washing with soap and water will prevent most (maybe even all) infection. But this is a poor understanding of reality.

Let’s start with condom use. Even with wide spread education campaigns, millions of Americans have unprotected sex with untested partners every single day. STD’s are still transmitted here and teen pregnancy (and other unintended pregnancies) still exist. It strikes me as near-racist to assume that we can throw education and condoms at people in Africa and get great results. They aren’t monkeys we first worlders get to train. People in Africa will largely behave how people around the globe behave. Some will use condoms. Some won’t. Some will be willing but unable. Sometimes people run out of condoms and want to have sex. Sometimes they will have sex where they don’t happen to keep their condoms. Sometimes they want to take a risk because it feels better. The “they” here is global.

It’s obviously true that condoms and education are key components in the fight against HIV. However, we should never limit ourselves to one option simply because it may be the most effective option. This fight isn’t a zero sum game; we can – and should – use every tool available. Doing so will literally save lives.

As for hygiene, even with rigorous cleaning practices, infections can still happen. I have a friend who got circumcised in his early 20’s for this exact reason. He showered every day and was specific about his cleaning regimen, but he still had issues. That won’t be the case for everyone, but it will certainly be the case for many. It’s far easier to entirely prevent this issue after birth than to force men to see doctors later in life for something that needn’t be an issue.

Ethics

The anti-circumcision crowd has lost on the scientific front. Circumcision protects against HIV and other STD’s. It reduces penile cancers and other infections. It doesn’t hurt and it doesn’t alter sensitivity. Aside from the minor risks of surgery (which exist largely by virtue of what surgery is in the first place), it literally has zero physiological drawbacks. That leaves the anti-circumcision folks with limited recourse in the debate. Enter the ethical argument.

There is effectively only one ethical argument against circumcision. It isn’t a good one, but it does have a basis in established ethical theory. However, before I address that argument, I want to address a common philosophical argument I hear. It isn’t technically about ethics, but we’re in the same ballpark. It’s the argument that says removing the foreskin in order to protect against disease is like removing a foot to prevent foot cancer or gout. Eventually, the argument usually ends with the suggestion of death in order to prevent all disease. Even without the especially absurd end, this is nothing more than an argumentum ad absurdum. Removing a piece of skin which has no discernible function and the loss of which has no negative consequence is not the same as removing a significant body part or altering the body in a way which affects quality of life negatively.

The primary ethical argument against circumcision – the argument from bodily autonomy – is slightly better. This argument says that it is wrong to permanently alter a person’s body without their consent for non-medically necessary reasons. That means a haircut is fine, or even a piercing (though there may be other objections to the latter). Indeed, any life-saving procedure is allowed under this argument. Like with most ethical arguments, there will be examples that raise gray areas (and those will generally come down to personal judgement calls more than anything), but there are certain things that are black and white. Tattooing one’s infant wouldn’t be allowed, for example. The child necessarily cannot consent and the procedure is absolutely not medically necessary, so there is not justification for it.

With circumcision, it is true that the procedure is not medically necessary. All the benefits laid out above are still very much true, but that doesn’t make the procedure necessary. A person who doesn’t get circumcised can live a perfectly happy life, free from all sexually transmitted diseases and infections. Indeed, billions have done and are currently doing it. Furthermore, it cannot be reversed. Once that foreskin is gone, it’s gone. Some people will say it can be returned, but it will simply be extra skin, at best.

Now let’s make a comparison.

Vaccines are some of the greatest achievements of science. Everyone should get at least the basic vaccines we expect people in the 21st century to have. And for those who live in certain areas or travel to certain areas, a number of other vaccines are recommended. For instance, I have a vaccine for yellow fever because I visited Tanzania about 5 years ago. If I visit any similarly at-risk location 5 years from now, I’ll get a booster shot first. All that said: vaccines are not medically necessary. Again, they’re fantastic and everyone should get them. Public policy should dictate all students must get them. These are things which save lives. But, again, they are not medically necessary. Even when polio was a significant public health concern, very few people actually died from the disease. Only a small minority of the population ever contracted it, and of that small minority, only a minority became sick at all. It was great when a vaccine became widely available. Lives were saved. But being unvaccinated did not put someone at active risk of sickness or death; being unvaccinated was a passive risk. This exactly mirrors the issue with circumcision. Furthermore, vaccines cause permanent change to the body via the addition of anti-bodies. This again mirrors the permanent change of circumcision.

The first counter to this comparison is generally to note that anti-bodies aren’t a visible change whereas removal of the foreskin is. The argument from bodily autonomy makes no such exception. The argument doesn’t say it’s wrong to permanently alter a person’s body without their consent unless you totally can’t see it. That would entirely gut the argument, making it into nothing more than a cosmetic argument. Something so superficial doesn’t pass any sort of ethical muster in my book. Besides, I’m not so sure the anti-circumcision crowd should be making a cosmetic argument anyway.

The second counter to the circumcision-vaccine comparison is to note that whereas vaccines add something to the body, circumcision actually removes something. I suppose that’s true, but I don’t see where such a distinction would matter within the argument from bodily autonomy. We can no more rid ourselves of anti-bodies than we can rejuvenate foreskin.

Before I reach the end of this post, I want to quickly recap the argument from bodily autonomy. The argument says it’s wrong to permanently alter a child’s body without his consent unless it’s for a medically necessary procedure. Neither circumcision nor vaccines are medically necessary. Both are highly effective and both save lives. Without either, we would have fewer people in the world, that’s for sure. However, neither one is required to live a long, happy, and healthy life. This, of course, is not an argument against either one. This is an argument against this incantation of the argument from bodily autonomy. That isn’t to say bodily autonomy isn’t important. It is. But it isn’t an argument that works under the auspices of libertarian ethics as applied to global health issues. That is, bodily autonomy is important because it is the best way to protect the individual and populations at-large; it isn’t important in and of itself/because it maintains liberty. (Dead people don’t have liberty.) Or to put it another way, bodily autonomy only works under a utilitarian framework.

Conclusion

This one is simple. Circumcision is a safe procedure that needn’t cause pain, doesn’t cause trauma (indeed, it can’t cause psychological trauma by definition), and it doesn’t affect sexual sensitivity, satisfaction, or performance. Furthermore, it reduces female-to-male HIV transmission, invasive penile cancers, UTI’s, STD’s, and general infections. Along with education and condom use, circumcision is a phenomenal tool in the fight against HIV; circumcision literally saves lives. The World Health Organization, UNAIDS, the Bill and Melinda Gates Foundation, a dozen and a half African health ministries, the CDC, and the AAP all support it as good health practice. The science and the ethics are in: Excepting for the minor (and rare) risks inherent with surgery by virtue of what it is, there are literally zero drawbacks to circumcision; when performed under sterile conditions and by medical professionals, circumcision increases the odds a boy will have a disease and infection free life.

Circumcision: The evidence still isn’t vanishing

Increasingly, circumcision is becoming a health policy in places where it is needed most. WHO, UNAIDS, and especially The Bill and Melinda Gates Foundation are some of the groups at the forefront of this fight against deadly diseases and infections. More recently we’ve seen American groups such as the American Academy of Pediatrics come out in favor of circumcision. This is in large part due to three extremely strong studies that came out in 2006, but those were really just the final straw. Evidence has been building for the effectiveness of circumcision in fighting disease and infection since the late 70’s, and more specifically it has been building against fighting HIV since the late 80’s. The evidence is in: Circumcision helps protect against infections, penile cancer, and STD’s, including HIV. It’s an extremely important tool that should be promoted around the world. And so, as the debate quickly pivots from whether or not circumcision is effective to figuring out why it is so damn effective, more organizations are coming out in favor of it in ever stronger terms:

U.S. health officials on Tuesday released a draft of long-awaited federal guidelines on circumcision, saying medical evidence supports the procedure and health insurers should pay for it.

The Centers for Disease Control and Prevention guidelines stop short of telling parents to have their newborn sons circumcised. That is a personal decision that may involve religious or cultural preferences, said the CDC’s Dr. Jonathan Mermin.

But “the scientific evidence is clear that the benefits outweigh the risks,” added Mermin, who oversees the agency’s programs on HIV and other sexually transmitted diseases.

I went into the circumcision debate many years ago without a dog in the fight. I was neither passionately against the practice nor fervently in favor of it; my general indifference parted greatly with what any Google search will show. However, as I began to hear more and more about the topic, and as I began to study global health issues more and more (especially during the time I was studying and volunteering my time in Haiti), I found my position slowly shifting. But it was indeed a very slow shift. With degrees in both biology and philosophy it was easy to be torn. The evidence had clearly tilted – at the least – in favor of circumcision, but what about the ethical arguments against it? I would need to resolve those concerns before I would support circumcision as a health policy. And that I did. The sole argument the anti-circumcision crowd has against circumcision is that it violates bodily autonomy. But so do other things which many in that crowd clearly support. Namely, vaccines can and do permanently change a person’s body for life without their consent. Looking at circumcision and vaccines, then, under the isolation of the argument from bodily autonomy, what’s the difference? They both change the body forever and neither is done with consent when done to infants/toddlers. The only responses I ever get to this is that vaccines are more effective or that the changes aren’t visible. Pshaw. They aren’t always more effective, and even where they are, so what? The argument from bodily autonomy doesn’t get to be put on the shelf when it’s convenient to ignore. The effectiveness of a procedure is irrelevant; all that matters is the necessity of the procedure. Vaccines and circumcision are both necessary to a healthier world, but neither is an absolute necessity to survival. Yes, more people will die without either, but that’s immaterial. And as for the changes being internal, I guess I wasn’t aware how aesthetics-focused the anti-circumcision crowd was.

I went on a bit of a rant there, but I hope it was effective. The ethical argument – singular, not plural – is weak. Yet the biological argument is strong. And as I learned more, it became quite clear that it was stronger than I initially thought. I freely admit that by the time I became involved in this debate (likely 2009, and as early as 2010 on FTSOS) I should have done all the proper research; I could have easily found myself where I am right now rather than going through a slow shift.

One of the things which always kept me tilted towards being pro-circumcision was the dogmatic attitude of the anti-circumcision crowd. It didn’t matter what evidence was presented to them, their ethical stance trumped everything. That would be fine, of course, since it would be a valid basis for opposition (even if I or anyone else disagrees with it). Unfortunately, this crowd has a habit of attacking perfectly valid science. PZ Myers did this back in 2011 when he said the following:

The health benefits. Total bullshit. As one of the speakers in the movie explains, there have been progressive excuses: from it prevents masturbation to it prevents cancer to it prevents AIDS. The benefits all vanish with further studies and are all promoted by pro-circumcision organizations. It doesn’t even make sense: let’s not pretend people have been hacking at penises for millennia because there was a clinical study. Hey, let’s chop off our pinkie toes and then go looking for medical correlations!

Emphasis mine. Clearly, whereas the organizations promoting circumcision as a health policy or recommendation have had a history of different positions on the matter, it’s ridiculous to say they’re inherently pro-circumcision. Moreover, the irony meter here is off the charts. The anti-circumcision crowd is incredibly vocal, despite being a scientific minority. Indeed, whereas the pro-circumcision groups came to their conclusions only after being presented with evidence, the anti-circumcision groups are composed entirely of people who oppose the practice on ethics first; they cherry-pick the science after the fact.

But that isn’t the important point here. As the title of this post says, the evidence of the benefits is not vanishing. It’s not vanishing with further studies. It’s not vanishing with time. It’s not vanishing at all. All we’ve been seeing is 1) more and more groups coming out in favor of the practice and 2) research focused on why it’s so effective. Myers is plainly wrong. (Of course, all the criticism by Myers is coming from a guy who once had a debate with Jerry Coyne where he said that no evidence could ever convince him of the existence of God. While I share his lack of theistic belief, I don’t share his position here. I can’t imagine a more anti-scientific thing to say than that there is no possible evidence that could convince me of something. I could be convinced unicorns exist. I greatly doubt that will happen, but it’s possible; denying these possibilities when speaking in abstract terms is doltish.)

Anyway.

[The new guidelines] are likely to draw intense opposition from anti-circumcision advocacy groups, said Dr. Douglas Diekema, a Seattle physician who worked on a circumcision policy statement issued by the American Academy of Pediatrics in 2012.

“This is a passionate issue for them and they feel strongly that circumcision is wrong,” said Diekema, a professor of pediatrics at the University of Washington.

Indeed, the head of one group did argue against the CDC’s conclusions on Tuesday, saying they minimize potential complications from the procedure.

The guidelines “are part of a long historical American cultural and medical bias to attempt to defend this traumatic genital surgery,” said, Ronald Goldman, executive director of the Circumcision Resource Center.

Notice the name of the anti-circumcision group in that quote: Circumcision Resource Center. Hmm, what other group of people try desperately to sound legitimate despite everything they hold dear? Perhaps it’s the people who run sites and groups like Evolution News and the Discovery Institute and the Geoscience Research Institute – creationist groups. Honestly, I’m not sure who should be insulted more by this association.

Thought of the day

The reason I don’t find the anti-cosmetic argument of anti-circumcisionists convincing is that these people usually aren’t arguing from any solid principle they’re willing to consistently hold. That is, the anti-circumcisionist argument states that a person’s bodily autonomy is important and should not be violated against his or her will except when medically necessary. That means if your baby has a potentially fatal or life-altering heart defect, for example, surgery is an okay thing to demand. Having foreskin, on the other hand, is not fatal or life-altering, and so circumcision is unjustified. But here’s the problem: vaccines cause the body to create antibodies that otherwise would not be there. This is a change to the body which, depending on the vaccine, may last forever. It isn’t an outward change like circumcision, but that is neither here nor there. If the anti-circumcisionists want to premise their argument on bodily autonomy, then any permanent change to the body is fair game.

Let’s review. Circumcision is not necessary for a quality life, nor is a lack of circumcision inherently fatal or life-altering. Vaccines, too, are not necessary for a quality life, nor is a lack of vaccination inherently fatal or life-altering. The differences that exist between these two examples are plenty, but when we’re talking purely about bodily autonomy? There isn’t a bit of difference. Circumcision permanently changes a part of the bodily. Vaccines permanently change the body’s antibodies. Each example, strictly speaking, can be argued to be a violation of a person’s bodily autonomy. Yet, except for the kooks and quacks, we never hear of any anti-circumcisionists wailing on about vaccines. Funny that. It’s almost as if their primary argument is a lie that isn’t based upon any principle at all.

A Gish Gallop post on circumcision

I posted my recent post on circumcision to my Facebook wall. It very quickly got a response, one being a number of links. I doubt the person was intentionally doing a Gish Gallop, but that was the effective result. Unfortunately, I felt compelled to respond in an effort to show just how wrong all linked studies and papers were. As I’ve said before, the only legitimate response the anti-circumcision crowd has to the practice of circumcision is one of ethics. Denying the lowered HIV transmission rate or rejecting the effectiveness of using circumcision as yet another tool in the fight against HIV just won’t fly.

Here is the link to all the studies. I responded to 10 out of 21 before I felt I had made my point. Each number matches the order in which the studies appear in the link:

1. This first study doesn’t address actual sexual sensitivity. It works off the hypothesis that there are nerve endings in foreskin. It shows nothing.

2. The second study’s “methods” was to solicit input from online sources using self-selected participants. If there’s anything I’ve learned about the anti-circumcision crowd, it’s that they will do anything to make circumcision look bad.

3. The circumcised men in this study had far more sexual partners than the uncircumcised men. I question how similar the sample groups actually were since there’s no reason one should be more sexually active than another simply due to circumcision.

4. This study also found a link between premature ejaculation and being from India. The results are more than dubious.

5. This isn’t a scientific critique, but rather one of economics. It’s wrong, first of all. Circumcision is very cost effective and lasts for life. Second, the article talks about the “haste” in the studies connecting HIV transmission and circumcision. I can only conclude that the authors aren’t aware that these studies go back at least 25 years.

6. Wow, where do I start with this one? The first point is simply false. Studies show exactly the opposite. The second point is misleading. They may have looked at three specific studies and had issues over how well they reflect real world conditions, but there are dozens upon dozens of studies on this matter, looking at it from the perspective of different ethnic and religious groups, different nations, different regions, etc. The evidence is robust here. The third point simply misunderstands what science is. Science works on a body of evidence, not individual studies. I can find maybe 5-10 studies questioning global warming. That doesn’t mean they’re right or worth mentioning compared to the thousands of others. The fourth point is hugely misleading. The problem of HIV transmission in the U.S. is largely focused on the homosexual community. Circumcision doesn’t offer much protection, if any, for anal intercourse. The point they are drawing is one of the most frustratingly invalid ones I hear. The fifth point 1) makes up a stat and 2) ignores that condoms aren’t always available in remote regions where HIV is the biggest problem. The sixth point is the only argument the anti-circumcision crowd has. The science is in, so they have to stick with ethics.

7. This claims a national survey showed that circumcision had no preventative effect. The evidence? First of all, it links to the wrong paper. The paper given from your site directs me to a paper which itself cites the actual paper. Second, the survey simply found similar rates of HIV infection amongst circumcised and uncircumcised men in South Africa. It said nothing of total numbers, of sexual partners, of religious and ethnic background, or any other factors.

8. This study compares the universal use of condoms to the universal use of circumcision then concludes that condoms are more effective. This isn’t news, nor is it a reflection of reality. Yes, condoms are more effective, but no, their use is not universal, nor will it ever be. We can’t even get American teenagers to use them universally. Do we expect to convince dozens of unique cultures to adopt them 100%? Of course not. This is a multi-pronged approach.

9. This study discusses issues I’ve addressed, including looking at real world conditions (again, it limits itself to 3 particular studies) and cost.

10. This study finds conflicting results as to the pleasure and enjoyment of sex/masturbation for circumcised men. Many men had less, some had more. Curiously, they seem happy to attribute the lessened pleasure to circumcision but fail to say anything about the increased pleasure. The better guess? There are cultural factors and stigmas at work here.

Circumcision as a public health policy

At this point it has been established that circumcision reduces female-to-male HIV transmission rates by around 60%. Like it or not, the science is in. Now the question has shifted to being about why it reduces transmission, as well as how we can best introduce circumcision has a public health policy. On the first point, the general answer is that the foreskin is a relatively large surface area subject to tearing and softer (non-keratinized) skin. On the second point, though, I wasn’t aware of any actual policies in place to save the lives of men and women in regions particularly vulnerable to the spread of HIV. As it turns out, multiple sub-Saharan countries have undertaken measures to dramatically increase circumcision rates – though much work is still required:

Zambia is still 75 per cent short of its target of two million circumcisions by 2015. So is Uganda, having completed 1.5 million towards its 4.1 million target. Kenya has achieved its target in numbers – but not among the “right” men.

The donors who are pouring cash into male circumcision following the landmark 2006 study which showed that it reduced the risk of HIV infection by 60 per cent, have neglected a crucial factor – the attitude of women.

A man who gets circumcised is often viewed as a man who is looking to sleep around as much as possible. And, indeed, this has become something of a problem, as HIV rates in some areas have remained steady. This may also be due to men not waiting the necessary 6 week healing period – 40% of newly circumcised men had sex while still healing, actually resulting in an increase in their likelihood of contracting HIV. Furthermore, we may be seeing the problem of moral hazards at play. This is where risk is reduced for one thing or another, so people are less cautious in return. Some examples are playground materials and car safety. In playgrounds, children are often getting hurt as much if not more than in previous years because they’re playing on soft wood chips or rubber, leading them to believe they can fall harder and get hurt less. With cars, safety has greatly increased and deaths have fallen, but accidents remain steady or on the rise. People with seat belts are willing to speed more than those without them.

But the real problem in these sub-Saharan nations is a lack of education and peer support:

Carol Musimami, one of 30 “technical advisers” who counsel the men, said: “You will see the older ones come after dark. They don’t want to be with the youth. We are targeting the 25 to 35-year-olds –they are the ones with the money, they buy the women, they are exposing themselves [to infection]. But they are hard to get. They don’t want others to know,” she says.

Leadership is key. In Kenya, the circumcision programme in Nyanza province in the west – one of the three centres in the landmark 2006 trial that proved its effectiveness – was faltering when Raila Odinga, the Prime Minister and a member of the non-circumcising Luo tribe, responded to protests from tribal elders fearing the loss of their identity by declaring: “We don’t lead with our foreskins, we lead with other faculties. This is a medical issue.”

The speech, in 2008, proved a pivotal moment and more than 500,000 Luos have since been circumcised.

This is a major issue in global health. Science can find all sorts of answers to major problems, but that doesn’t mean it’s all just a matter of policy implementation after that. For instance, Jimmy Carter and WHO launched a campaign to eradicate Guinea worm disease in 20 African nations in the 1980’s. The primary approach to this was to make sure people had clean drinking water. With funding, wells were built and larvacide was added. However, one of the biggest pushes was to get people to drink clean water was to give them simple cloth filters. Unfortunately, this came with two problems. One was simply logistical: the filters clogged. The other was that the cloth material was too aesthetically pleasing, so people would often use them as decorative items. When the Carter Center, Precision Fabrics, and DuPont worked together to distribute plain nylon cloth filters (and education), the problem quickly shrank. There were 3.5 million cases of Guinea worm disease in 1986. As of 2005, the number had dropped to 11,000. This underlines the need for cultural understanding in addition to the simple cold science of the matter. Greater peer interaction and promotion of circumcision may be the key in getting places like Zambia to that 2 million goal.

At any rate, I’m very pleased to hear about these ongoing efforts to spread circumcision in developing nations in order to curb the spread of HIV. This is a triumph of common sense, global health initiatives, science, and basic humanity.