Call to circumcise ignores the evidence

The argument for widespread circumcision relies on the proposition that we face a public health crisis to which genital surgery is the only answer. The most prominent exponent of this view, Emeritus Professor Brian Morris, has described circumcision as "a biomedical imperative for the 21st century," and is never wanting pulpits from which to preach his gloomy message. As the American biologist P.Z. Myers points out, in a reply to to his latest offensive, there is nothing much new here; he has been peddling this sort of stuff for over a decade.

But whatever disease-related problems Africa faces, such as HIV – for which adult (not child) circumcision has been proposed – there is no evidence that any developed nation is threatened with any such crisis. Apart from its air of unreality, such "ten minutes to midnight" scare-mongering ignores the principles of risk management. This requires that a full assessment of consequence, likelihood, mitigation strategies and risk tolerance be undertaken before it is possible to reach any conclusions about the degree of risk inherent in taking or not taking certain actions. Individuals have different levels of risk tolerance, and they have the right to develop their own strategies for handling health risks, and striking the appropriate balance between dangers and pleasures. The health industry is not entitled to pre-empt their options.

Circumcision advocates perform a subtle logical slide. They present a mass of data and claim that it is proof that parents should circumcise their baby boys. In fact, even if their data were valid, it is merely evidence that an adult male should consider getting himself circumcised. A few cautious males might make this choice, but since most men are understandably reluctant to sacrifice a sexually significant part of their own penis, the strategy of the circumcision lobby has been not to persuade men to circumcise themselves, but to pressure parents to circumcise their children. The problem here is that if an adult male would not elect such an operation for himself, it is ethically wrong to force it on somebody else merely because he lacks the power to resist.

Non-therapeutic circumcision of non-consenting minors has never been justified because its proponents have failed to specify what would have to be established to make their case worth considering. In order to make a convincing case they would need to prove (a) that the boy had a high risk of contracting a seriously disabling and incurable disease before reaching the age of consent unless he was circumcised; (b) that circumcision would certainly eliminate the risk or reduce it by a degree proportional to the sacrifice of the body part; and (c) that there was no other practical way of reducing the risk by the same degree. No such proof has ever been achieved.

A century ago E. Harding Freeland urged universal circumcision of young boys as a preventive of the world's then most feared disease, syphilis. He was, however, less evasive than today's circumcision promoters, and made no bones about the fact that he was advocating "the universal practice of an operation which has for its object the wholesale removal of a certain healthy structure as a preventive measure". He thus admitted that he had to provide "good evidence" that (1) the operation was free from risk; (2) the removal of the foreskin would inflict no physical disability on the individual; and (3) the benefits of the amputation were substantial and commensurate with the sacrifice. He failed to establish any of these claims, and his counterparts today, strive as they might to throw numbers at us, do little better.

The diseases most commonly cited as necessitating widespread circumcision are sexually transmitted infections, HIV-AIDS, cervical cancer in females, penile cancer and urinary tract infections. The first three of these are sexually transmitted and thus irrelevant to children, who – not being sexually active – are plainly not at risk. In the case of cervical cancer, a safe and effective vaccine against human papilloma virus (HPV), the main causative agent, has made the question of circumcision as irrelevant as mercury as a treatment for syphilis.

Penile cancer is a very rare cancer of old men with readily detectable and treatable abnormalities of their foreskin, severe phimosis, or poor hygiene, and often a history of smoking. Men with normal foreskins who observe ordinary hygiene are at no greater risk of penile cancer than circumcised men.

UTIs are of potential relevance, but the consensus of responsible medical authorities, such as the Royal Australasian College of Physicians, is that the risk is nowhere near great enough to justify general pre-emptive amputation, and a recentCochrane Review found no reliable evidence that infant circumcision provided any protection. Professor Morris's claim that uncircumcised boys are ten times more likely to contract a UTI sounds impressive, but as Brian Earp and Robert Darby explain in forthcoming article in the UK Skeptic Magazine, it is not enough to show an increased risk of UTIs among uncircumcised boys because the actual significance (i.e., clinical importance) of this risk needs to be assessed in a meaningful context.

The context is this: the "10-fold" difference in incidence of UTI is what you get when you divide two very small percentages against each other: 0.15% (for circumcised boys) and 1.5% (for intact boys), with overall rates being low in either case. This is the same thing as saying that UTI does not occur in 99.85% of circumcised infant males and in 98.5% of uncircumcised infant boys. In the rare event that some unlucky child does become infected, UTIs are both easily diagnosed and treatable, with few side-effects and rapid recovery. So why all the fuss?

As for some the minor issues, it is obvious that you cannot experience phimosis if you lack a foreskin with which to experience it; but then, without testicles or a prostate you won't be at risk of testicular or prostate cancer. With the sudden male breast cancer scare, perhaps Professor Morris will advocate routine removal of infant male breasts. After all, they serve no functional purpose, and are probably of less sexual significance than the foreskin. Among the many advantages, removal in infancy is cheaper, less risky and less painful than doing it in adulthood; and, best of all, unlike adults, infants cannot refuse consent.

Morris's strained analogy of circumcision with vaccination has been rejected on previous occasions as irresponsible, unscientific and misleading, and by critics of his most recent effusion (both prominent child health experts) as "frankly preposterous" and "extremely worrying" and absurd: according Professor Kevin Pringle, head of paediatrics at University of Otago, "to compare the risks of circumcision with the risks associated with vaccination is just not true." As for the idea that circumcision should be made compulsory, Toronto physician Ali Rizvi has described it as "the dumbest proposal ever".

Vaccination offers proven, strong protection against deadly, contagious diseases of children, now rare precisely because of vaccination. (It is this rarity that the anti-vaccination movement exploits, leading to sporadic outbreaks of those diseases). Circumcision, by contrast, offers only slight, debatable or disproven reductions in the risk of minor problems and rare diseases of late onset that can be better prevented by other means, or treated as they occur. The anatomical results also present a contrast: vaccination does not involve the excision of sensitive tissue from the penis. (See box below)

In his latest sermon on the evils of the foreskin, Professor Morris cites the American Academy of Pediatrics' assertion that the benefits of the operation outweigh the risks. But since the AAP admitted that it was unable to quantify the risks it was logically impossible to reach such a conclusion. To make matters worse, the AAP conceived the risk/benefit trade-off incorrectly, since it defined risk as nothing more than surgical complications (bleeding, infection, death etc). Surgical complications are only a small element of the harm of circumcision. The standard it should have applied is prospect of benefit vs risk of harm, thus factoring in the value of the foreskin to the individual and the ethical harms of denying him a choice and violating normal principles of bioethics and human rights. Obviously, assigning zero value to the foreskin makes it much easier to assert that the benefits of removal outweigh the surgical risks.

The question is not whether circumcision might conceivably have some minor health benefits some time in the imponderable future, but (1) whether those benefits are great enough to justify removal of the a significant part of the penis without the informed consent of the individual; and (2) whether the foreskin is too valuable to lose unless absolutely necessary. As the Canadian ethicist Margaret Somerville has remarked, "If we view a child's foreskin as having a valid function, we are no more justified in amputating it than any other part of the child's body unless the operation is medically required treatment and the least harmful way to provide that treatment."

Eight reasons why vaccination is not like circumcision

• Vaccination confers immunity against specific diseases; even if the extravagant claims of its advocates were correct, circumcision could do no more than reduce the risk (and not by much). Nobody will become immune to any disease by virtue of circumcision.
• Vaccination adds to the body's natural immune system; circumcision amputates a large and visually prominent part of the penis.
• Vaccination provides protection against diseases to which children are at risk and which the may spread to others. Of the diseases to which circumcision is supposed to provide protection, only UTIs are found in children.
• Vaccination provides protection against diseases that are are highly contagious. The diseases against which circumcision is supposed to provide protection are either non-contagious (UTIs, penile cancer) or of low virulence (STIs and HIV) – meaning that they are not easily communicated from one person to another.
• Vaccination leaves at most a small spot or lump; circumcision disfigures and scars a man in his most sensitive region for life.
• Vaccination is an injection; circumcision is major surgery, accurately described as pre-emptive amputation.
• Vaccination does not diminish the functionality of any body part; circumcision has documented adverse effects on the function of the genitals.
• Vaccination is scientific medicine, with proven protective value; circumcision is a relic of Victorian quackery.