"Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western countries. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention." ~ The College of Physicians and Surgeons of British Columbia

https://www.cpsbc.ca/files/u6/Circumcision-Infant-Male.pdf

Bob's stats and assertions are false. Amputation of the foreskin (circumcision) is not safe. It has no medical value. It amputates a normal, healthy, necessary part of the male genital tract and creates an abnormal, scarred penis that is missing up to 50% of its skin and it's main 'command and control' nerve center and has a mere 25% of the sexual sensation that is would have had if it were left alone. It cannot possibly function as it is supposed to and is uncomfortable and unpleasant for its owner's female sexual partner. Women who have had it both ways *definitely* prefer the man with the full package!
The STD transmission "rates" are conjecture. It used to be thought that amputating the foreskin reduced cervical cancer in female sex partners. That turned out to be nonsense and these other STD claims will turn out to be nonsense too. It's also a red herring argument, because not all males are going to have the same risk factors. How can you determine a male's sexual orientation and sexual behavior when he's under a year old? Condoms, diaphragms and dental dams are highly effective and, unlike circumcision, are 100% reversible.
Some men who have been mutilated need to continue the mutilations on the next generations to keep from facing the fact that they have had something taken from them for no reason at all. This is one of the most dreadful and damaging aspects of genital mutilation traditions, which circumcision absolutely is.

"and has a mere 25% of the sexual sensation that is would have had if it were left alone." -- what an extraordinary claim! There is no evidence that this is the case. Indeed, the largest study to date, with more than 1,300 volunteers, found that circumcision actually increased sensation. http://www.ncbi.nlm.nih.gov/pubmed/18761593

"Women who have had it both ways *definitely* prefer the man with the full package!" -- These women? http://www.ncbi.nlm.nih.gov/pubmed/19522862 Or these? http://www.circs.org/index.php/Library/Williamson

"The STD transmission "rates" are conjecture. It used to be thought that amputating the foreskin reduced cervical cancer in female sex partners. That turned out to be nonsense" -- actually, there's strong supportive evidence for it, largely as a result of reduced risk of HPV infection.

"and these other STD claims will turn out to be nonsense too" -- you can see that in your crystal ball, can you? :-)

The only person who can legitimately say whether or not the sensations from his intact foreskin have value is the man himself.

I don't have a lot of confidence in studies from Africa that promote circumcision by members of the pro-circumcision lobby like Bailey, Moses, Wawer, and Gray.

Regarding the Williamson study from thirty years ago, if my son wants to have sex with women from Iowa his grandmothers age, perhaps he should get circumcised. However I am confident that women in his generation will not have the same sexual hang-ups that women in his grandmother's generation had.

If someone proposed cutting the genitals of girls to reduce the risk of HPV infection in men, people would be outraged. In my opinion there is no ethical difference between using the reduced risk of HPV infection in women as a justification for cutting the genitals of boys and using the reduced risk of HPV infection in men as a justification for cutting the genitals of girls. Furthermore because there is a vaccine for HPV, it is unethical an inappropriate to use HPV as a justification for cutting the genitals of children.

"I don't have a lot of confidence in studies from Africa that promote circumcision by members of the pro-circumcision lobby like Bailey, Moses, Wawer, and Gray." -- I think that's a circular argument: you're labelling these people as "members of the pro-circumcision lobby" because they've published studies finding positive things about circumcision, and as a result of that label you distrust their work.

"Regarding the Williamson study from thirty years ago, if my son wants to have sex with women from Iowa his grandmothers age, perhaps he should get circumcised. However I am confident that women in his generation will not have the same sexual hang-ups that women in his grandmother's generation had." -- so basically you're rejecting evidence in favour of speculation?

Bailey and Moses have been promoting male circumcision for decades.

Cutting the genitals of a boy in 2011 based on the sexual preferences of women who are old enough to be his grandmother is crazy!

"Bailey and Moses have been promoting male circumcision for decades." -- how would you define "promoting" circumcision, and are you able to come up with a rigorous, objective way of distinguishing this "promotion" from publication of results finding benefit to circumcision, as might reasonably be expected from scientific researchers?

Nate, the issue there is that there are many forms of female circumcision, from a simple pin-prick to draw one drop of blood, to cutting off and sewing up everything. People often only believe in the latter, but apparently the former is far more common. Not that I agree with any cutting off of any body part with a serious medical reason.

There are many forms of male circumcision too, from just cutting off the excess "overhang" to "high-and-tight" which usually ends up with issues in the man (as an adult) having painful erections or causing a slant or bend in his penis.

The trouble is, the level of risk of all circumcisions are risks that can cause serious problems, when the medical benefits are slim at best (and studies show claims of benefits are frequently biased and/or flawed) and can be cured or corrected with non-invasive means.

A good site to review is DoctorsOpposingCircumcision.org where medical experts give facts. It is disappointing that many doctors in the USA were never taught about the foreskin, many of their books in the USA assume all men are circumcised and have no information about care of a foreskin, so they tend to resort to "cut it off". Not the solution to any other part of the body in a modern society, except as a very last resort.

Sorry, that should have read "117 babies DIE per year in the USA".

"I will have to disagree with Bob's information on benefits, as over the years I have been doing research, the UTI statistics were agreed to be from a flawed study which (being based in the USA in the 70s) only had premature babies, in intensive care, as not circumcised, all with catheters. It was determined that this biased the study." -- it's surprising, really, that in your years of research you didn't discover that many studies have investigated the association between circumcision and UTI. These have taken place in a variety of settings and have used a range of methodologies, and they have consistently confirmed the results of the early studies. For a review of twelve such studies, see: http://www.circs.org/index.php/Library/Singh-Grewal

"Even as such the figures only showed UTI was in 1 in 194 babies." -- depending on the study, UTI rates in uncircumcised infants in the first year of life are usually in the range 0.9-2%. Over a lifetime, a reasonable conservative estimate is 20%.

"Cancer and circumcision is not argument, as the figures by the American Cancer Society state that penile cancer only occurs 1 in 109,000 cases." -- the annual risk is usually quoted as about 1 in 100,000; the lifetime risk is about 1 in 1,400.

"Hardly an argument compared to the risks (which includes an estimated 117 babies per year in the USA)." -- it doesn't make a lot of sense to compare one benefit to all of the risks; it's much more logical to compare the sum of each.

"Sorry, that should have read "117 babies DIE per year in the USA"." -- nonsense. That estimate was based on the flawed assumption that the difference between male and female infant mortality rates could be explained entirely by circumcision. See: http://circumcisionnews.blogspot.com/2010/05/fatally-flawed-bollingers-circumcision.html

Because there are effective, non-invasive ways to prevent and/or treat the medical conditions that male circumcision is supposed to prevent, it is unethical and inappropriate for a doctor to cut off a normal part of a healthy boy's penis.

Because there is NO compelling medical reason to cut of a normal part of a healthy boy's penis, even one death resulting from male circumcision is one too many.

"Because there is NO compelling medical reason to cut of a normal part of a healthy boy's penis, even one death resulting from male circumcision is one too many." -- not a very rational argument. For each death attributable to circumcision, how many would be attributable to lack of circumcision? There *are* risks associated with each choice, and it's meaningless to consider only one set of risks.

Ethical medical practice requires doctors to use effective, less-invasive methods of prevention and treatment before they use surgery. Because there are effective, less-invasive methods of prevention and treatment for the rare medical conditions that male circumcision is supposed to prevent, it is unethical and inappropriate for a doctor to use surgery.

Stan, we're not just talking about circumcision performed for the sole purpose of preventing disease, so the issue you raise is a moot point. Frequently, circumcision is performed as a result of weighing pros and cons, both medical and non-medical. Even so (and indeed even if the parents are completely unaware of the medical benefits), the risk of certain diseases is reduced.

The idea that American doctors are cutting the genitals of children for non-medical, cultural reasons when there is NO compelling medical reason for the surgery is shameful!

It is time for American doctors to put down their knives and to start to respect the rights of boys to decide for themselves whether or not they want to have a normal part of their own penis cut off.

"The idea that American doctors are cutting the genitals of children for non-medical, cultural reasons when there is NO compelling medical reason for the surgery is shameful!" -- seems perfectly reasonable to me. Do you also find removal of birthmarks to be shameful? Cosmetic dentistry?

A healthy, intact foreskin is NOT a birth defect!

It is disturbing that you would try to compare a normal part of the human body with a birthmark which is a congenital abnormality or with crooked teeth.

I agree, Stan, it's not a birth defect. The reason why I asked those questions was that I wanted to find out whether you found surgery in the absence of compelling medical reasons to be inherently shameful.

You've evaded my question, but reading between the lines you appear to agree that such surgery isn't inherently shameful. The question, then, is why you find one kind of surgery in the absence of compelling medical reasons (in your opinion) to be shameful, but not another kind. What is the key distinction? Does whether something is classified as a birth defect - which is, after all, an essentially arbitrary classification - really make that much difference to you? I'm genuinely curious.

Jake "Over a lifetime, a reasonable conservative estimate [for UTIS] is 20%."
OK. Even taking that (ridiculous) estimate, for every FIVE people you circumcise, FOUR of them didn't protect aginst UTI (more actually, since circumcised guys still get UTIs).

That's still an absurd waste of surgical resources (not to mention risk of infection, pain, loss of human rights, etc. etc.)

And even more so, circumcising one thousand three hundred and ninety-nine babies to prevent one old man (who probably neglected his hygiene) from getting penile cancer (let alone dying from it).

By Jake's own figures, circumcision is poor value.

"OK. Even taking that (ridiculous) estimate, for every FIVE people you circumcise, FOUR of them didn't protect aginst UTI (more actually, since circumcised guys still get UTIs). That's still an absurd waste of surgical resources" -- could you explain how you're making this assessment, Hugh7?

"not to mention risk of infection" -- using figures from Weiss' recent systematic review, the total complication rate for infant circumcision is 1.5%. Infection would be less than this, but for the sake of argument let's assume it's 1.5%. That would mean that for every infection endured as a result of circumcision, roughly 13 urinary tract infections would be prevented. So the net risk of infection is decreased. And that's just looking at a single benefit.

"By Jake's own figures, circumcision is poor value." -- a CDC study has shown that it's cost-effective in terms of preventing HIV alone; that study didn't address other benefits. http://dx.plos.org/10.1371/journal.pone.0008723

There are effective, non-invasive ways to treat UTIs in both boys and girls. Ethical medical practice requires doctors to use effective, non-invasive method of prevention and treatment before they use surgery.

The study by the the CDC did not include the value that a man may place in his own intact penis in their analysis.

"The claimed 60% of HIV/AIDS is from 3 studies done in Africa, have many scientists pointing out the serious flaws in their methodology" -- this is a wild exaggeration. The studies are accepted by the vast majority of scientists in the field, as a quick PubMed search will verify. Only a fringe minority challenge the results.

"and how the 3 studies do not even correlate with each other (which implies there are other factors not taken into account, thus their findings are erroneous)." -- what are you talking about? The results are remarkably consistent with each other.

"USAID reviewed HIV in various countries and the percentage of men circumcised or not." -- it would be enormously expensive to do so for the entire population of a country. What you're referring to is a series of observational studies, in which *samples* of men were taken from each country, and these data were gathered.

"It is particularly suspicious that the countries where the "60% studies" were chosen to be done, are all in the 8 out of the 18 countries where HIV is less in circumcised men already." -- or, to put it more accurately, two of the three studies were performed in countries where a USAID observational study found higher rates among uncircumcised men.

(continued)

"This feels like someone taking a survey of religious beliefs, standing outside a synagogue! It's not surprising their results were skewed." -- the mistake you're making here is to confuse correlation and causation. Observational studies are inherently susceptible to confounding, because, for example, there can be associations between circumcision and religious beliefs, and associations between religion and HIV, that can cause an apparent association between circumcision and HIV. The purpose of randomised controlled trials, which are experimental rather than observational, is to break these associations through the process of random assignment to the control or intervention group.

"The UNAID report determined that HIV and circumcision have no association." -- no, it didn't. http://www.measuredhs.com/pubs/pdf/CR22/CR22.pdf

"However, it is interesting to look to the USA which has high circumcision and high rates of HIV, whereas Europe has low rates of circumcision, and low rates of HIV." -- rather pointless, really. Such a comparison fails to isolate the effect of circumcision among the other differences (such as lower condom usage in the US).

Jake ignores the right of a man to decide for himself whether or not he wants to have a normal part of his penis cut off without his consent and without a compelling medical reason.

I would rather practice safe sex and use a condom instead of having a normal part of my penis cut off.

Even if such a right existed, Stan, it would be completely irrelevant to the issues that were actually being discussed. Would it hurt to read what people have said before replying?

Cutting the genitals of children when there is no compelling medical reason for the surgery is primarily an ethical and human rights issue.

Jake: "Even if such a right existed"

Not long ago some people opposed the right of others to be free from slavery or a woman's right to vote and hold public office or a girl's right to be protected from genital cutting. Marking the bodies of children for cultural or religious reasons, whether it is scarification, branding, or genital cutting, violates the rights to the children to bodily autonomy. The genital cutting of children, whether it is African girls or American boys, is a practice that should have no place in civilized society in the twenty-first century.

"Not long ago some people opposed the right of others to be free from slavery or a woman's right to vote and hold public office or a girl's right to be protected from genital cutting." -- that may be so, but it does not mean that opposition to a proposed right in any way validates that right.

Stan: "Jake ignores the right of a man to decide for himself whether or not he wants to have a normal part of his penis cut off without his consent and without a compelling medical reason."
Jake: "Even if such a right existed,..."

If such a right does NOT exist, then it would be all right to walk up to Jake in the street* and cut his glans off. OK? If not, why not?

*Well, for the sake of propriety and hygiene, drag him into a nearby ambulance. We can quibble about the details some other time.

"...it would be completely irrelevant to the issues that were actually being discussed."

Whenever you cut part of a babies' genitals off, you deprive the wo/man s/he is to become of the right to decide to keep them, so the absence of a compelling medical reason is crucial.

That reason would have to be so compelling that the billions of the worlds' men with foreskins are somehow being seriously disadvantaged. Well, we're not.

"If such a right does NOT exist, then it would be all right to walk up to Jake in the street* and cut his glans off." -- I guess I made the mistake there of discussing the "right" that Stan intended to express rather than the one that he actually expressed. What Stan is discussing is the "right" to a foreskin.

[Re "...it would be completely irrelevant to the issues that were actually being discussed."] "Whenever you cut part of a babies' genitals off, you deprive the wo/man s/he is to become of the right to decide to keep them, so the absence of a compelling medical reason is crucial." -- I've just checked, and neither BryTee nor I had actually mentioned circumcision of infants at all in this thread. The subject of the discussion was whether circumcision protects against HIV.

I am discussing the rights of all children, both boys and girls, to be protected from any surgery, cutting, scarification, branding, etc. unless there is a compelling medical reason for the procedure.

You're free to discuss whatever you want, obviously, but if you're going to discuss something unrelated to the parent post, could you post it as a new comment rather than a threaded reply?

Jakew: ""If such a right does NOT exist, then it would be all right to walk up to Jake in the street* and cut his glans off." -- I guess I made the mistake there of discussing the "right" that Stan intended to express rather than the one that he actually expressed. What Stan is discussing is the "right" to a foreskin."
Stan said "a normal part of his penis". His foreskin is a normal part of his penis, so you have no mandate to go reinterpreting him. Is the right to a foreskin somehow different from the right to a glans? How? (I can't find the reference, but I have seen a report of a man whose glans was accidentally cut off, leaving his foreskin, who was still able to function sexually, so no difference there.)

"Stan said "a normal part of his penis". His foreskin is a normal part of his penis, so you have no mandate to go reinterpreting him." -- I think Stan and I know each other well enough that I know what he meant.

"Is the right to a foreskin somehow different from the right to a glans?" -- it's a moot point. It doesn't matter whether you're talking about a foreskin or a kidney; in no case would it be all right to perform surgery without consent.

Jakew: "It doesn't matter whether you're talking about a foreskin or a kidney; in no case would it be all right to perform surgery without consent."

Q.E.D. Zing! Thank you for playing.
(Except that Jakew doesn't seem to agree with the Bioethics Committee of the AAP that ""...[P]roviders have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses. ... The pediatrician's responsibilities to his or her patient exist independent of parental desires or proxy consent.")

'Except that Jakew doesn't seem to agree with the Bioethics Committee of the AAP that ""...[P]roviders have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses. ... The pediatrician's responsibilities to his or her patient exist independent of parental desires or proxy consent."' -- on the contrary, I completely agree with that, and with the AAP's assessment that parents are best placed to determine what is in the best interests of the child. Thus, parents determine whether there is a need for circumcision, and provide consent, hence no problem.

There is NEVER a "need for circumcision" for a healthy non-Muslin / non-Jewish boy!

How can it ever be in a non-Muslim / non-Jewish boy's best interest to have a normal, healthy part of his penis cut off?

"There is NEVER a "need for circumcision" for a healthy non-Muslin / non-Jewish boy! How can it ever be in a non-Muslim / non-Jewish boy's best interest to have a normal, healthy part of his penis cut off?" -- parents may reasonably weigh medical and non-medical benefits and risks and conclude that it is the best option. The AAP's assessment is that parents are best placed to make this determination, not Stan Barnes.

The ONLY person who can legitimately decide whether or not there is a benefit or harm from cutting off a normal part of HIS penis is the man HIMSELF once his is an adult. You and the AAP ignore the rights of men to make that very personal decision about their own body.

One can't ignore a right that doesn't exist, Stan.

It took many years for people to accept that all humans have a right to be free from slavery or to accept that women have a right to vote. Future generations will look back on the people who argued against a male's right to genital autonomy the same way we now look back on people who argued against the right to be free from slavery or who argued against a woman's right to vote.

No one has a right to cut off a normal part of my body without my consent and without a compelling medical reason. Not a doctor. Not a religious leader. Not even my parents.

"If you disagree, look up the definition of mutilation." -- Here you are: http://www.thefreedictionary.com/mutilated Which of the senses do you think apply? None of them seem to, as far as I can see.

"10-20 thousand nerve endings." -- one often sees this figure claimed, but the fact is that no study has ever counted their number.

"PS. JAKEW has a vested interest in circumcision. He own's and maintains circumcision fetish web-sites and comments on all articles using outdated and biased information." -- I see you prefer to make defamatory allegations rather than addressing what I've actually said.

Jake: "10-20 thousand nerve endings." -- one often sees this figure claimed, but the fact is that no study has ever counted their number.

It is shameful that American doctors have been amputating a normal part of infant boy's genitals for decades without first doing the basic research to learn what it is they are cutting off.

It doesn't really matter how many nerve endings are removed, Stan. Anti-circumcision activists only quote a number because it *sounds* impressive (I suppose that's the nice thing about making up facts: one can invent ones that sound good). Nobody exclaims, "wow, that was 13,437 nerve endings" during intercourse. The number doesn't matter. What matters is what they do - does removing them affect sexual sensation or satisfaction? That issue has been studied, and while the evidence is a little inconsistent, it certainly doesn't indicate, on balance, any significant adverse effect.

The ONLY person who can legitimately say whether or not the nerves in HIS penis affect HIS sexual sensation and satisfaction is the male himself. Because there is NO compelling medical reason for cutting off a normal part of a healthy boy's penis, the decision should be left for him to make as an adult.

One of my favorite quotes is from Maya Angelou, "When you know better, you do better."

Because there is NO compelling medical reason to cut off a normal part of a healthy boy's penis, each man should be able to decide for himself whether or not HE wants to have a normal part of HIS penis cut off.

Thanks John. Much appreciated.

And you're not alone: http://www.circumstitions.com/Resent.html

"I'm confident that most people understand the fundamental difference between correcting a congenital abnormality and cutting off a normal, healthy part of a child's body without a compelling medical reason. I am surprised that you can't see the difference." -- presumably this is in response to my comment for which I've provided a link below. Could you explain why you think I believe there to be no difference between the two?

http://parkville.patch.com/articles/moms-talk-circumcision-rates-are-declining-in-the-us#comment_594516

"It is ethically wrong for a doctor to cut off a normal, healthy part of a child's body (foreskin, labia minora, earlobe, little toes, etc.) if there is no compelling medical reason for the surgery." -- yes, that doesn't really answer my question, though, does it?

And she is not alone: http://www.circumstitions.com/coerce.html

"Jake, there is no reasoning with you, you are a sick individual. You are aroused sexually by the idea of helpless babies having their genitals cut up. That is a fact." -- don't be so absurd, Greg. That isn't a fact; it's a libellous allegation, and it is completely irresponsible of you to make such claims.

Or rather, Shakespeare portrayed Othello as despising it. But in "Love's Labours Lost" a character calls his foreskin "My sweet ounce of man's flesh!" When everyone had one, they valued it.

"To understand the effect of circumcision it is necessary to look towards studies with more rigorous methodologies, and these show that it has a protective effect."

Jake is absolutely right we NEED more rigorous methodologies to determine WHY we see no real world evidence for the alleged reductive effects for circumcision. But the problem is, we DO have an abject failure to fulfill prediction, and for an explanation for this failure all we get are vague unquantified excuses.

SCIENCE accepts excuses as evidence--NOT!

"Jakew: Now, circumcision is roughly 50% effective in preventing HIV transmission, so the ineffectiveness of condoms plus circumcision is 2.5%-10%. This corresponds to a combined effectiveness of 90-97.5%."

I am surprised Jake commits such an elementary mistake. You can't just add them. The men in the circumcision experiments were supposedlly using condoms. This requires a controlled experiement involving thousands aof men divided into four arms, two (circumcised and non) using condoms, two not using them. Unethical you say? Then how is it ethical to perform these Tuskegee-like experiments on African men using circumcision?

"I am surprised Jake commits such an elementary mistake. You can't just add them. The men in the circumcision experiments were supposedlly using condoms." -- the difference between the groups is therefore circumcision vs lack of circumcision; the ratio of risks is the same whether both groups are using condoms or both groups aren't using condoms.

Jakew assumes without evidence that circumcision has no effect on the rate of condom use. We have abundant evidence that this is not the case. And reported condom use is not necessarily the same as condom use, in a non-double-blinded experiment where the paid volunteers for circumcision were all well aware of the desired answer to every question.

"Jakew assumes without evidence that circumcision has no effect on the rate of condom use" -- actually, although a small number of studies have suggested an effect, the majority indicate that there is none.

I would not trade one cell of my sexual anatomy for a decreased incidence of STD, cancer or infection. My anatomy is mine alone. Without the foreskin, the male, along with his partner, is deprived normal, natural intercourse. Circumcision is a human right's violation.
There is no reason to cut the skin off a newborn baby or child. No one can predict his future. Circumcision, with certainty will predict that the boy will grow up to be denied his sexual human right of intact genitals.
Yes, there is a huge difference between sex whole and cut. If you were cut, it is not your fault, but please do not propagate this suffering.

Randall, I have read the paper you mention. It's utter nonsense. Have you looked at it in any depth? Of the first three refs, no.s 1 and 3 fail to support the claims for which they're cited. The following three references are cited in support of a ridiculously complicated mess of rough calculations in which the authors attempt to claim that a substantial fraction of the infections in the HIV trials were not sexually acquired. Amusingly, they manage to contradict themselves here: for example they claim: "Men who reported no sexual partners for the duration of the trial accounted for [...] 6 infections [so] at most 35 of the 67 infections in the Ugandan trial can be attributed to sexual transmission".

I could go on - it's such a dreadful paper that there's no shortage of holes - but I think you probably get my point.

I'm absolutely astonished. How can you even talk about ethical considerations while engaging in character defamation? Don't you feel even slightly hypocritical?

It's only defamation if it's untrue. Are you challenging my assertion? If we're going to talk moral crimes, I'd rate defamation way below taking scissors to the genitals of children with no good reason. Nice deflection, though.

"It's only defamation if it's untrue. Are you challenging my assertion?" -- of course.

"If we're going to talk moral crimes, I'd rate defamation way below taking scissors to the genitals of children with no good reason." -- if circumcision is believed to be in the best interests of the child, I can't see why you can reasonably call it a moral crime. Certainly it's unnecessary, but that doesn't mean that it has no benefits. Certainly it's risky, but those risks are no greater (and are arguably somewhat smaller) than the risks associated with not doing it.

"If it's unnecessary, and it's permanent, and it's risky, and it can't be consented to by the individual, then how can you argue in favour of it being ethical?" -- as I said above, the fact that it's unnecessary doesn't mean that it has no benefits. Lots of things in life aren't strictly necessary, but we choose them because they're beneficial. And that includes decisions that parents make for their children. Vaccinations, for example, aren't strictly necessary, but they're beneficial. And they're often permanent, risky, and are often performed without the child's consent (and no, I'm not saying that vaccinations and circumcision are exactly alike; I'm just using them as an illustrative example).

Ultimately, the most important question in ethics is, I believe, protecting the vulnerable from harm. That is, if something represents a net harm, then it is an ethical imperative to protect the vulnerable from it. On the other hand, if something is neutral or a net benefit, there is no ethical problem. In the case of circumcision, it's clear that there's no net harm, hence no ethical problem.

"I'm interested to see the autopsy reports of minors who've died as a result of having complete penises." -- I wouldn't hold your breath. The fraction of cases of disease attributable to circumcision is statistical; it's usually not possible to say with certainty that a particular case is caused by lack of circumcision.

"Lots of things in life aren't strictly necessary, but we choose them because they're beneficial."

What other tissue can we routinely remove from children at birth? Not breast buds. Not tonsils. Not appendices. I fail to find anything comparable, except sunnat in Malaysia. The vaccination analogy is a red herring - children are vaccinated for childhood illnesses, and is recommended by every health organisation in the world. There aren't many who advocate for infant circumcision - the stance taken by health authorities has gone in quite the opposite direction in the last few decades.

"I wouldn't hold your breath. The fraction of cases of disease attributable to circumcision is statistical; it's usually not possible to say with certainty that a particular case is caused by lack of circumcision."

If there are infant deaths directly attributed to circumcision - under-reported, for sure, but one will do - and you can't prove one death from lack of circumcision, then how can you say there is 'no net harm', let alone ascertain that the risks from not being circumcised are equal to or greater than the risks of being circumcised? I'd be interested to see what these infants are 'statistically' dying from. It's ludicrous, of course, to assert that surgery on a highly vascular part of a neonate's body won't sometimes result in haemorrhage and death, or more commonly necrosis and glans amputation. It's a bold statement to put forward that circumcised infants are somehow safer.

"What other tissue can we routinely remove from children at birth?" -- I can't think of any other surgical procedure that wouldn't result in a net harm. Can you?

"The vaccination analogy is a red herring - children are vaccinated for childhood illnesses, and is recommended by every health organisation in the world." -- but that wasn't the criterion you specified. You said "unnecessary". It's not reasonable to change that in mid-discussion.

"There aren't many who advocate for infant circumcision - the stance taken by health authorities has gone in quite the opposite direction in the last few decades." -- my impression has been that most authorities (with the exception of the Dutch) have moved towards more positive stances in recent years.

"If there are infant deaths directly attributed to circumcision - under-reported, for sure, but one will do - and you can't prove one death from lack of circumcision, then how can you say there is 'no net harm'" -- because it's trivial to show that deaths must occur due to lack of circumcision.

"I'd be interested to see what these infants are 'statistically' dying from" -- UTIs while they're infants (and later on, too), HIV and penile cancer when they're older.

"It's ludicrous, of course, to assert that surgery on a highly vascular part of a neonate's body won't sometimes result in haemorrhage and death" -- but nobody has claimed such a thing. The risks are small, but they do exist.

(continued)

"It's a bold statement to put forward that circumcised infants are somehow safer." -- May I refer you to "Risks from circumcision during the first month of life compared with those for uncircumcised boys"? http://www.ncbi.nlm.nih.gov/pubmed/2562792

I hadn't read that paper, Randall, but thank you for bringing it to my attention. It appears to be consistent with the findings of the studies cited below:

Michael RT, et al. Private sexual behavior, public opinion, and public health policy related to sexually transmitted diseases: a US-British comparison. Am J Public Health. 1998 May;88(5):749-54.

Weinberg MS, et al. AIDS risk reduction strategies among United States and Swedish heterosexual university students. Arch Sex Behav. 1998 Aug;27(4):385-401.

Brick P. How does Europe do it? Fam Life Matters. 1999 Winter;(36):3)

Yes, Randall, I've read Michael et al. What point are you trying to make?

I have read it, Randall, but it's difficult to know what to make of it. Altschul doesn't tell us much about the data that he actually examined; he says only that it took place at Northwest Permanente Hospitals. He doesn't say how many UTI cases were involved, which makes it difficult to understand whether his results can be generalised to the wider population. And even if that were clear, it still wouldn't clarify the relationship to circumcision.

Hospitals will not typically *want* to divulge those statistics unless legally required to do so. Malpractice is a touchy topic in the USA where healthcare reform is being challenged. I'm sure there are statistics but not necessarily. Because circumcision is EASY MONEY for the practitioner (thanks to fee-for-service) it may be just lumped in with other problems.

As to Wiswell's twenty-year-old study - it is well-known that the only boys who escaped circumcision in military hospitals in the 1980s were premature, and prematurity is the biggest risk factor for UTIs (besdies being born a girl). No one since has come to the same conclusion as Wiswell, as far as I'm aware.

"Who, with the exception of the USA? I'd be interested to see policy statements to back this up." -- not sure why you're excluding US organisations, but since you ask, there's the World Health Organisation, which in 2007 recommended circumcision as a preventative against HIV in certain circumstances, and the RACP, which in 2010 adopted a more pro-parental choice policy, adding the words "it is reasonable for parents to weigh the benefits and risks of circumcision and to make the decision whether or not to circumcise their sons" to their policy (among other changes).

"You've not proven that these UTIs would be prevented by circumcision." -- see link to Singh-Grewal, below.

"The studies showing that circumcision 'prevents' HIV or penile cancer (rare) are sketchier still (not to mention they are not risk factors for minors)." -- it's difficult to tell whether you're serious or not. More than 40 observational studies have investigated the association between circumcision and HIV; the majority of these (21 of 27 in Weiss' 2000 meta-analysis) have found a protective effect. More importantly, three randomised controlled trials (a much higher standard of evidence) have all found a protective effect.

(continued)

"No one since has come to the same conclusion as Wiswell, as far as I'm aware." -- again, are you serious? Every UTI/circumcision study to date has found essentially the same results. For example, see Singh-Grewal's meta-analysis of 12 such studies: http://www.circs.org/index.php/Library/Singh-Grewal

'Let me get this straight, Jakew makes a cite, and it's good enough to stand on it's own. Randall makes a cite, and we need to provide where we got that information and "what point are you trying to make?"' -- Regarding Randall's point, it isn't clear why either of the quotes he included are relevant to circumcision. They don't refer to it. I'm afraid I don't know what you're referring to regarding "where we got that information".

'it still remains to be scientifically proven just "How does cutting off the foreskin prevent the transmission of HIV?" -- that's true. There are a variety of plausible explanations, many of which have strong supportive evidence (such as in-vitro evidence showing that Langerhans cells are vulnerable to HIV), but the exact mechanism is not known with certainty. My personal suspicion is that it's likely to be a group of mechanisms rather than just one.

"You're hoping we read: Circumcision reduces the risk of UTI. and stop" -- well, the issue being discussed is whether circumcision reduces the risk of UTI, so it seems logical to present evidence addressing that question. Do you disagree?

"And then we read three lines down: Given a risk in normal boys of about 1%, the number-needed-to-treat to prevent one UTI is 111." -- a more questionable assertion. It's true that the risk is about 1% in the first year of life, but over a lifetime it's considerably greater than this.

"REALLY?! What are the odds my boy is going to be in that ONE that needs it? And when he does need it, like anything else, it can be done as painlessly and easy as you say it is." -- that's fair enough: a reasonable parental decision. There is a risk that UTI may cause serious damage before it can be treated, but it's only a very small risk, certainly not enough to make the decision against infant circumcision an irresponsible one.

It's greater possibly because of poor hygiene? So you'd rather spare the adult the shame of seeing a urologist and chop up some innocent child?

"It would be interesting to note how many of these boys still contracted UTIs if they weren't prematurely retracted." -- well, in one of those studies the participants were grown men, so clearly premature retraction can't explain that!

"Schoen et al have a religious barrow to push where circumcision is concerned. If we're to accept the validity of his conclusions, then similar studies by Muslim researchers in Malaysia showing the protective value of circumcising girls must be equally valid." -- which studies are you referring to?

"Again, I'd really like to see a comparison of infant deaths due to foreskin as compared to deaths due to circumcision, if you really wish to justify it as 'protective'." -- I've already cited Wiswell's paper looking at just the first month of life (http://www.ncbi.nlm.nih.gov/pubmed/2562792), which included such a comparison.

"Since you're in the UK, are you aware of many full-term intact infants dying from UTIs? I've not seen data on this." -- there's limited data available. Wiswell (cited above) found 2 deaths in 88 UTIs (2.3%), Schnadower found adverse events in 2.8% of cases (the definition included death, but the abstract doesn't provide data for deaths alone).

"Again, I'd really like to see a comparison of infant deaths due to foreskin as compared to deaths due to circumcision"

AMEN!! especially since I have seen many DOCUMENTED cases of death FROM circumcision, but nary a single one from being intact.

Perhaps Jake can spare citting questionable studies and provide this empirical evidence?

Since foreskin presence is a sign of normality, one would assume it is healthy until symptoms appear that indicate otherwise. If no symptoms appear, no death can be attributed to the presence of normality and health.

About Wiswell's link between foreskin and UTI: how does he know that the mere presence of a foreskin caused these UTI deaths? How can it be proven?

"Since foreskin presence is a sign of normality, one would assume it is healthy until symptoms appear that indicate otherwise. If no symptoms appear, no death can be attributed to the presence of normality and health." -- death is usually a fairly reliable indicator that the body is in poor health (obviously). So the question is, what is the cause of death, and is this cause associated with lack of circumcision?

"About Wiswell's link between foreskin and UTI: how does he know that the mere presence of a foreskin caused these UTI deaths? How can it be proven?" -- the association between the foreskin and UTI is well-proven, thanks to a large number of studies of various settings and designs, including an RCT. It is proven that the two deaths in Wiswell's study were caused by complications of UTI. It is not proven, however, that the foreskin was responsible for the two deaths in Wiswell's study; the numbers were too small to establish statistical significance, and in any case the study design could not establish causation.

Death, dear Jake, is an extreme circumstance that is due to some extreme conditions: trauma, process of aging, dehydration, uncontrolled coagulation cascade, nourishment and infection of vital organs. I'm sure there are other categories but these are the main ones. So, if something results in death it was such a immediately severe occurrence that there was no chance that rapid intervention would have helped (trauma) or intervention was either too late or insufficient. Death by UTI is impossible. Death by invasive or systemic infection after UTI is certainly not immediate and points to signs that the UTI is untreated or unchecked. This very idea should be looked closely for malpractice. Urinalysis and urine culture easily checked and can spot an infection very quickly... usually within as little as 24 hours. Microorganisms do not grow to killer proportions in minutes.

So about the Wiswell link, you said "it is not proven" that foreskin has anything to do with these deaths. So... why do you keep throwing this crap at the wall and hoping it sticks? Foreskin is not the cause of death. PERIOD.

"Death by UTI is impossible. Death by invasive or systemic infection after UTI is certainly not immediate and points to signs that the UTI is untreated or unchecked." -- it's difficult to know what to make of this: you seem to acknowledge that death due to UTI is not impossible, which contradicts yourself.

"So about the Wiswell link, you said "it is not proven" that foreskin has anything to do with these deaths. So... why do you keep throwing this crap at the wall and hoping it sticks? Foreskin is not the cause of death. PERIOD." -- Of course it isn't proven that these two deaths were caused by the foreskin itself: given that the association between lack of circumcision and UTI is statistical, it's not possible to say that for any given case it was caused by the presence of the foreskin. But it is clear from Wiswell's data that: 1) that a certain, non-zero fraction of UTIs are fatal; 2) that deaths are no more common in circumcised infants, and may be less common.

I'm not implying anything. Death by UTI is impossible. If the UTI is left untreated and spreads - it is not necessarily a UTI anymore. It just means that the urethra is the entry point for invasive pathogenic organisms.

But you do agree that death can be an indirect result of UTI?

Indirectly, possible ... but not proven to be caused by the presence of foreskin. Death is usually caused by organ failure secondary to systemic bacteremia which is secondary to UTI. This is perfectly preventable (and treatable) without removing body parts.

"This is perfectly preventable (and treatable) without removing body parts." -- If it's perfectly preventable and treatable, and if this prevention and treatment actually occurs, then the death rate due to complications of UTI ought to be zero. On the other hand, if it's non-zero (as it clearly is) then that indicates either that it's imperfectly preventable and treatable, or that this prevention and treatment is imperfectly used, either of which indicate that the model in which prevention and treatment is perfect diverges from the real world.

The definition of preventable is able to prevent. If the infection is allowed to progress to a point beyond the site of origination and allowed to go systemic then it comes increasingly untreatable. If the infection is allowed to progress to this point obviously a circumcision does no good - even if it did any good otherwise. Antibiotics are only as good as the personnel prescribing and dosing it.

As far as the non-zero death rate is concerned, every medical procedure has a non-zero death rate. An acquaintance I met years ago died on operating table (revived, though) from exploratory abdominal surgery. People have died from dental work. These are quite possibly necessary surgical procedures. Circumcision is not proven to be necessary from the evidence you've provided. At best, it is a fanciful procedure (for mere aesthetics) with claims for extra benefits that the child will most likely never need ... as a child.

In the first months of life, less invasiveness, jostling and prodding is needed. I'm sure delivery is as stressful for the child as it is for the mother (hahaha! and the dad - if there is one).

"If the infection is allowed to progress to this point obviously a circumcision does no good - even if it did any good otherwise." -- no argument here, though of course circumcision before the initial infection might have prevented it in the first place.

"Circumcision is not proven to be necessary from the evidence you've provided." -- unsurprisingly, as I haven't tried to prove such a thing. It is rarely necessary. That is not to say that it is not beneficial, of course.

I didn't say you did - I'm just trying to construct an appropriate paragraph. Connecting the dots is essential.

Well, I still think that the benefits primarily rest with the adult and not the child. If there is a reduced risk of HIV, an adult is the one that should be targeted for the procedure and not the child.

"Actually, UTIs peak at 3 months." -- um, not quite: the peak during infancy is the first few months of life.

"Almost nothing to 50 years" -- not really "almost nothing". The source you cite says "5-8 per year per 10,000", which over a 50-year period works out at 2.5-4%.

"and then it raises due to prostate issues." -- yes, the reported lifetime risk for the US is 13.7%.

Why are you raising this point, Dave? I can't tell which post you're replying to, and the context will affect the importance of your remarks.

"I'm saying that the Wiswell study that compares kids healthy enough to be circumcised vs. kids not in any condition to be circumcised is limited, at best." -- okay, there are plenty of other UTI studies, so if you prefer you can get confirmation of the association with lack of circumcision from these. The ratio between UTIs in circumcised and uncircumcised males is broadly similar in all studies.

"Since when is 3 months not equal to "the first few months of life", and why do we care? Correcting me in my timeline accepts that it still peaks. ...at a whopping 1%." -- I agree that 3 months is the first few months; the correction was that this is the peak during the infancy period, not the peak overall.

"While the 50 year average is 2.5-4%... and the benefits of circumcision in urinary tract infections more or less 'end' after the first year..." -- no, the benefit persists throughout life.

There are quite a few studies conducted among older children, though not as many as of infants. There is relatively little evidence among adults, but what little there is indicates that the protective effect continues into adulthood. In both cases, see Table 1 of Singh-Grewal et al for citations, though a number of studies have been published since that paper.

There are effective, non-invasive ways to treat UTIs in both boys and girls. Ethical medical practice requires doctors to use effective, non-invasive methods of prevention and treatment first, before they use surgery. Because there are effective, non-invasive ways to prevent and/or treat the rare medical problems that male circumcision is supposed to prevent, it is unethical and inappropriate for a doctor to cut off a normal part of a healthy boy's penis.

Why should babies be punished for a disease of choice in adults? This is a horrible way to "practice" preventive medicine. No wonder America has THE highest medical costs in the world. (yet people forget that we do not have the best outcomes and life expectancy doesn't reflect cost)

"A number of men have posted comments here stating that they feel that they have been harmed by male circumcision." -- that doesn't necessarily mean that they *have* been harmed.

Common sense and basic human decency indicate that cutting off a normal, healthy part of a child's genitals without a compelling medical reason causes harm. The only person who can legitimately say whether or not he has been harmed by having a normal part of his penis cut off without his consent and without a compelling medical reason is the man himself. If a man feels that he has been harmed by male circumcision, I respect his opinion.

What it boils down to, is do I wish for my son, like my daughter, to be spared unnecessary genital cutting and make his own choices regarding his sexual future? Do I want him to be spared the small but very real risk of death, and the certainty of harm and the loss of a sensitive body part, or be 'statistically' and 'hypothetically' protected from death from an affliction circumcision may or may not prevent? It seems a clear choice to me and most other parents around the world.

However, I'm reminded once again that you can't fight stupid. If there are parents who engage in the genital cutting of their children because a computer software engineer told them to, or some great bunny in the sky told them to, then so be it.

"Do I want him to be spared the small but very real risk of death, and the certainty of harm and the loss of a sensitive body part, or be 'statistically' and 'hypothetically' protected from death from an affliction circumcision may or may not prevent?" -- ah, I see: you're of the "statistics aren't real" school of belief. Ironically, you're typing your comment on a computer that absolutely depends on the statistical behaviour (and quantum mechanics is *completely* statistical) of billions of transistors. But ... okay.

"Again, Jake, I see a lot of comments along the lines of 'we don't have data on that' when it comes to the number of lives that circumcision supposedly saves, yet you're still willing to claim that circumcision saves them, at rates high enough to justify the continuation of genital cutting. Yet at the same time, you claim that it's trivial to take note of the deaths that occur from the cutting itself." -- no, Amy, I said "it's trivial to show that deaths must occur due to lack of circumcision". And it is. For example: HIV is fatal in many cases (most, eventually). Circumcision reduces the risk of HIV. Therefore circumcision must prevent a certain number of HIV-related fatalities. This is a trivial application of logic.

Now, as for deaths due to circumcision itself, yes, they do occur, unfortunately. The best available data indicate that they occur at a rate of about 1 in 500,000. But it's easy to show that this figure is smaller than deaths due to the relatively rare penile cancer that is attributable to lack of circumcision.

And no, I'm not saying that this "justifies" circumcision; all of the deaths involved (in developed countries at least) are so rare that I think decisions can reasonably be made on other grounds. But it does place the deaths due to circumcision in perspective.

(Sorry for replying in reverse order here.)

"I saw table one, but I couldn't make heads or tails of the 'n' value vs. overall sample size" -- was there any particular reason why you couldn't just look up the sources, if you had a particular need for this information?

"Jake likes to bring up a lot of dubious studies that are only supported by other circumcision advocates to support his claim, but he can never directly answer the question of the ethic of using "studies" to amputate normal, healthy tissue from a healthy, non-consenting child." -- would that be the same ethical question that I addressed in the following post? http://parkville.patch.com/articles/moms-talk-circumcision-rates-are-declining-in-the-us#comment_600128

Your so-called "ethical question" is based on a few assumptions:

"Lots of things in life aren't strictly necessary, but we choose them because they're beneficial. And that includes decisions that parents make for their children. Vaccinations, for example, aren't strictly necessary, but they're beneficial. And they're often permanent, risky, and are often performed without the child's consent (and no, I'm not saying that vaccinations and circumcision are exactly alike; I'm just using them as an illustrative example)."

Circumcision cannot come anything close to a vaccine. You'd like for it to be, and you try your hardest to try to dilute yourself and others that it is, but it is not. A vaccine does not cut off any part of the body. A vaccine functions by immunizing the body against microbes that cause disease; when HIV enters the body, it really doesn't matter that you are missing your foreskin... or your finger... or your nose.

"Ultimately, the most important question in ethics is, I believe, protecting the vulnerable from harm."

Circumcision, unless there is a medical necessity for it, is deliberate harm. It really doesn't make sense, the idea of "protecting your child from harm" by deliberately harming your child.

"Ultimately, the most important question in ethics is, I believe, protecting the vulnerable from harm. That is, if something represents a net harm, then it is an ethical imperative to protect the vulnerable from it. On the other hand, if something is neutral or a net benefit, there is no ethical problem. In the case of circumcision, it's clear that there's no net harm, hence no ethical problem."

No, ultimately, the most important question in ethics is; is the child in need of surgery? Is the child suffering from a condition from which he will die unless he is circumcised? Have all other alternatives to amputative, and permanently altering surgery been tried and failed? Can the so-called "benefits" of surgery be obtained in any other way?

The bottom line is thus; unless there is medical or clinical indication, cutting off part of a child's genitals is harm; it is a deliberate wound. It is genital mutilation.

Unless there is medical or clinical indication, doctors have no business cutting off parts off of healthy, non-consenting individuals, much less pretend like they can give parents any kind of "choice."

"Circumcision cannot come anything close to a vaccine [...]" -- I actually acknowledged that they were different. If you disagree with what I wrote, wouldn't it make sense to highlight something that we actually disagree about, rather than expanding on something that we agree upon?

"Circumcision, unless there is a medical necessity for it, is deliberate harm." -- utter nonsense. Of course it isn't.

"The bottom line is thus; unless there is medical or clinical indication, cutting off part of a child's genitals is harm; it is a deliberate wound. It is genital mutilation." -- nonsense. If there is no medical indication it is non-therapeutic, but that doesn't imply harm or mutilation.

"utter nonsense. Of course it isn't." - OK, you say so... I'll take your word for it... ;-)

"-- nonsense. If there is no medical indication it is non-therapeutic, but that doesn't imply harm or mutilation."

What are you talking about. Of COURSE it does! Not like I'm expecting a known circumcision fetishist to acknowledge this though...

Anyway, gotta bugger off... See you next time, OK?

"OK, you say so... I'll take your word for it... ;-)" -- you seem to expect me to take your word for your own claims; surely you should extend me the same privilege.

[Re "If there is no medical indication it is non-therapeutic, but that doesn't imply harm or mutilation."] "What are you talking about. Of COURSE it does!" -- no, it doesn't. Absence of medical indication does not imply harm. A vaccination, for example, is typically performed without pre-existing medical conditions, but does not cause harm (again, I'm not saying that vaccinations and circumcision are alike; I'm just using this as an example to show that lack of medical indication does not imply harm). And none of the senses of 'mutilate' even refer to the presence or absence of medical indications (see, for example, http://www.thefreedictionary.com/mutilated).

"Not like I'm expecting a known circumcision fetishist to acknowledge this though..." -- No matter how often you repeat it, it still won't be true...

"If you want to make the claim that circumcised boys are less likely to die as a result of having been circumcised, you need to prove that more lives are saved than taken by male genital cutting. This is something that you've been unable to do." -- actually, I've already done so: Wiswell's paper shows that to be true using UTIs alone. But here's another demonstration, using penile cancer:

Suppose we take two million boys, and circumcise half. That means we've got one million circumcisions. Given a risk of death of 1 in 500,000, that means we should expect two deaths due to circumcision.

We should also expect some deaths due to penile cancer -- to estimate their number, we'll use the most conservative estimate of the relative risk in uncircumcised males (2x), the overall lifetime risk in the US (1 in 1,437), and the prevalence of circumcision (79%). (If you want citations for these, just ask.) We can therefore calculate the risk in circumcised males using algebraic manipulation; it's 0.058%, or 575 cases. Using a conservative 5% mortality rate, there are therefore 29 deaths due to penile cancer, plus two due to complications of circumcision.

Now, in the uncircumcised group, we should expect twice the number of penile cancer cases: 1,150, and 58 deaths. This is slightly less than twice the number in the circumcised group: circumcision saved 27 lives.

Jake continues to ignore the fact that there are effective, non-invasive ways to prevent and/or treat the rare problems that male circumcision is supposed to prevent. It is unethical for a doctor to use surgery to prevent a rare medical problem when there are effective, non-invasive methods of prevention and treatment.

"Jake continues to ignore the fact that there are effective, non-invasive ways to prevent and/or treat the rare problems that male circumcision is supposed to prevent." -- Stan, if these ways *are* widely used then the available statistics will reflect the result of their use, and if they're *not* used then they're unrealistic ideal-world and hence should be ignored when estimating expected cases.

"It is unethical for a doctor to use surgery to prevent a rare medical problem when there are effective, non-invasive methods of prevention and treatment." -- who said anything about circumcision *for the purpose* of preventing penile cancer? I wasn't aware that we were discussing that specifically. Circumcision for any reason, though, has the same effect. (It's odd to be having this conversation yet again, but there we are.)

It is unethical for a doctor to cut the genitals of a healthy child unless there is a compelling medical reason for the surgery. Why do advocates of male genital cutting even mention UTIs and penile cancer if they are not attempting to justify cutting the genitals of healthy boys?

"It is unethical for a doctor to cut the genitals of a healthy child unless there is a compelling medical reason for the surgery" -- so you keep claiming, Stan.

"Why do advocates of male genital cutting even mention UTIs and penile cancer if they are not attempting to justify cutting the genitals of healthy boys?" -- I have no idea; you'll have to ask them. *I'm* mentioning them here in order to put the risk of death due to circumcision in proper perspective.

I think most descent, thoughtful people will agree that it is unethical for a doctor to cut the genitals of a healthy child unless there is a compelling medical reason for the surgery.

Why on earth would anyone cut off a normal part of a child's genitals if there is no compelling medical reason?

"Why on earth would anyone cut off a normal part of a child's genitals if there is no compelling medical reason?" -- Tiemstra identified the following reasons: "ease of hygiene (67 percent), ease of infant circumcision compared with adult circumcision (63 percent), medical benefit (41 percent), and father circumcised (37 percent)". Adler et al identified a number of reasons, including: "Health reasons", "Looks like father", "Religious practice", "Looks like peers", "Looks like brother(s)".

African parents give many of the same reasons for cutting their daughters' genitals.

Very possibly. Your point is?

Cutting the genitals of children for cultural reasons is a harmful practice that should have no place in a modern civilized society. Most Americans are appalled that loving African parents still cut their daughters' genitals for cultural or religious reasons, but the reasons given by American parents for cutting their sons' genitals are similar to the reasons given by African parents for cutting their daughters' genitals.

It is past time for responsible, caring adults in American and Africa to end the cultural practice of cutting the genitals of children when there is NO compelling medical reason for the surgery. It is a issue of basic human decency.

"Most Americans are appalled that loving African parents still cut their daughters' genitals for cultural or religious reasons, but the reasons given by American parents for cutting their sons' genitals are similar to the reasons given by African parents for cutting their daughters' genitals." -- The mistake you're making, Stan, is to assume that just because the reasons for the practice may be similar, the practices themselves are alike. That's a logical error. FGC and circumcision are not the same thing; one is without doubt a net harm, while the other is (according to reasonable observers) neutral or a net benefit.

Last year the American Academy of Pediatrics proposed allowing doctors to cut the genitals of girls if her parents requested it for cultural reasons. The AAP recognized the similarities between cutting the genitals of boys for cultural reasons and cutting the genitals of girls for cultural reasons. They sought to end the sexist double standard that allows doctors to cut the genitals of boys, but not cut the genitals of girls.

People from cultures that practice female genital cutting do not view the practice as harmful. In the same way that people from cultures that practice male genital cutting think that a normal intact penis has no intrinsic value, people from cultures that practice female genital cutting think that a normal intact vulva has no intrinsic value.

It's difficult to know what point you're trying to make, Randall. Could you explain?

Apparently Jake has difficulty comprehending why one would want to post data that refutes his claims

"Ease of hygiene is one of the silliest reasons given by pro-circumcision activists for cutting the genitals of healthy children. Shame on you for even mentioning it!" -- What? Stan, you *asked* why people choose to circumcise their children: "Why on earth would anyone cut off a normal part of a child's genitals if there is no compelling medical reason?" I answered, giving reasons that were offered by parents in a study. I'm sorry that you don't *like* that reason, but to berate me for mentioning it is irrational, since you didn't ask me to supply reasons that you'd like.

"Cleaning a normal, intact penis is not rocket science! It takes 3 seconds for a man to clean his penis in the shower." -- that may be so, but many uncircumcised men don't clean, as you know from the evidence I've given you previously.

Jake, we have indoor plumbing in this country with hot and cold running water! It's easy for a boy or man with a normal, intact penis to keep himself clean. I am surprised that you would try to give legitimacy to such a silly reason for cutting off a normal, healthy part of a child's genitals.

If my parents had cut off a normal part of my penis because they thought I was too stupid or too lazy to keep myself clean, it would be very hard for me to ever forgive them.

Stan, whether you or I consider a reason to be valid is really beside the point: since there is no net harm from circumcision it is legitimate to choose it for virtually any reason. However, I think it is certainly true that it is *easier* for an circumcised male to cleanse his penis - in fact, it takes special effort to shower without doing so. In contrast, it does take a special effort for an uncircumcised male to do so (I'm not saying that it's difficult, just that it is *more* difficult), and probably as a consequence of this the uncircumcised penis is, on average, less clean.

The only person who can legitimately say there is no net harm from cutting off a normal, healthy part of his penis is the man himself. Your suggestion that a doctor can preform surgery on a child for "virtually any reason" when there is no compelling medical reason for the surgery is bizarre.

Jake: "the uncircumcised penis is, on average, less clean."

I am tired of ugly, bigoted comments like this about men with normal, intact genitals. If you made a similar comment about any ethnic group or nationality, most people would recognize the ugly, bigoted cultural bias inherent in the comment.

Cutting the genitals of a child instead of teaching him or her proper hygiene is absurd!

"Looking like the father is another silly reason given by pro-circumcision activists for cutting the genitals of healthy children." -- actually, Stan, it's a reason given by parents in a study of reasons for circumcision. It's an answer to your question.

Unless they are a family of nudists most boys will never see their father's penis after early childhood. Explaining the difference to a boy in an age appropriate way is easy. I am surprised that you would try to give legitimacy to such a silly reason for cutting off a normal part of a healthy boy's penis.

I haven't given it legitimacy, Stan, nor have I denied it legitimacy. I haven't commented on its legitimacy at all. I'm just answering your question. You asked, to remind you: "Why on earth would anyone cut off a normal part of a child's genitals if there is no compelling medical reason?" This was given as a reason by 37% of parents in Tiemstra's study, so any reasonably comprehensive answer to your question would *have* to include it.

Most boys don't care that their penis looks different from their father's. Cutting the genitals of a child so that the father does not have to face the fact that a doctor cut off a normal part of his penis without a compelling medical reason is lame.

I neither know nor care about religion, so I have no comment about that. However, if parents (of whatever religion) believe that they have religious reasons, that is an answer to your question. By arguing with each of the reasons given, you seem to indicate that when you asked why people would circumcise you actually meant to ask for reasons that would meet with your personal approval. I wish you'd said so: it would have saved a lot of time.

In my opinion there needs to be a compelling reason before it is ethical for an adult to cut off a normal part of a healthy child's body. Which of the reasons you quoted are compelling enough to justify cutting off a normal part of a boy's penis without his consent?

Male circumcision is NOT a Christian practice. The New Testament is very clear on that point of Christian doctrine.

"If everyone jumped of a bridge, would you?" -- no, but if everyone drank water and ate fresh vegetables, I'd be happy to follow suit. It wouldn't be rational to make a bad decision because everyone else has done so, but equally it would be irrational to reject a decision just because everyone else has done so.

"The newborn circumcision rate is close to 50% in the United States. In the western states the newborn circumcision rate is well below 50%" -- indeed, it varies by geographical region. Some areas have very high circumcision rates; others very low.

No matter where he lives, an American boy born in 2011 will have peers who have a normal, intact penis.

Not necessarily. Some areas have extremely high circumcision rates, bordering on 100%.

If the newborn male circumcision rate in a community borders on 100%, then the doctors in that community are probably doing a hard sell for unnecessary genital surgery on boys. Cutting the genitals of boys is easy money for unethical doctors.

Even if a boy grows up in a community with a very rate of male circumcision he will probably move to a more progressive community when he leaves home.

"There is NO compelling medical reason for a doctor to cut off a normal part of a healthy boy's penis." -- in your opinion. It may be compelling in the view of the decision-makers.

The ONLY person whose opinion is relevant is the man whose penis it is. Every person has a right to decide what permanent body modifications are done to his or her own body. Because there is NO compelling medical reason for cutting off a normal part of a healthy boy's penis, male circumcision is just another form of permanent body modification like genital piercing, scarification, tattoos, etc.

Stan, I understand that you feel strongly about this, but the simple fact is that parents can and do decide upon infant circumcision.

Yes, but only for little boys these days.

The right of little girls to be protected from all forms of genital cutting has been seen as more important than the right of parents to cut their daughters for over a decade. Hopefully one day soon little boys will enjoy the same protection from genital cutting as little girls.

Indonesian parents can and do decide to circumcise their daughters, but that does not make it an ethical decision. In my opinion there is no ethical difference between an Indonesian doctor cutting the genitals of a healthy girl without a compelling medical reason and an American doctor cutting the genitals of a healthy boy without a compelling medical reason. It is past time for all doctors to put down their knives and stop cutting the genitals of healthy children.

Strange. So you see no ethical difference between something that's a net harm and something that isn't?

Indonesian parents do not think circumcising their daughters causes a net harm. Culture and religion causes good people to overlook the harm of cutting the genitals of healthy children, both boys and girls.

"Circumcision has killed over 100 babies each year" -- utter nonsense. Bollinger's claim (to which you refer) was arrived at by mistakenly assuming that differences between male and female infant mortality rates were solely due to circumcision. A more realistic estimate is 2.

"and here in the U.S. we've had 2000 amputations" -- source?

Even one death from medically unnecessary surgery on a healthy child is one death too many!

Not this nonsense again, Stan! Considering deaths due to circumcision in isolation is irrational. One must also consider the deaths prevented by that circumcision.

Medical ethics is not nonsense, Jake. The principles of medical ethics require doctors to use effective, less-invasive methods of treatment before they use surgery. There are effective, non-invasive methods of prevention and treatment for the rare medical problems that male circumcision is supposed to prevent.

Once again Stan, if we were talking about circumcision for the sole purpose of preventing disease, your point might be relevant. However, since that is rarely the case, it's not.

The fact that American doctors are still cutting the genitals of healthy children for so-called cultural reasons in 2011 is shameful. If there is no compelling medical reason for the surgery, it is unethical for a doctor to cut the genitals of a child.

Perhaps in your system of ethics, Stan, but it seems safe to say that many people would disagree.

I can't believe that in America in 2011 there can be such a compartmentalization/rationalization of the procedure. Our society disallows any elective procedure (much less cosmetic procedure!) to any person for any reason to which the patient THEM SELF can not consent.... unless you are a neonatal boy. This is sexist, ageist and medically unethical. It can not be compared to any other treatment that anyone can think up because circumcision is invasive and removes healthy tissue which can not be replaced. It medically unethical and medical organizations have the duty to uphold the standards of medical conduct REGARDLESS where medical assistance is required. To allow physicians/nurses/surgeons or whoever is performing these procedures to slide on by and maybe going so far as covering it up is criminal.

No one can sway me from this opinion. Parents rights....blah blah blah. Medical "studies" ... blah blah blah. It doesn't make anything good or right. It's just sugarcoating. It's all a way of saying, we're going to do this and I don't care how you feel now or in the future. It's all a way of saying, shut up and sit down. It's all a way of saying, you are a man and you should not be expressing those feelings or emotions. You have no right to question your parents. You have no right to question medical authorities... they are the experts and you'll do what they say.

I hate elitism.

"Jake, since you have never had sex with a foreskin" -- an interesting claim. On what basis do you hold this belief?

"Circumcised sex is inferior to whole sex, for the man and woman." -- studies are not, as a rule, consistent with this claim. The evidence generally indicates that circumcision results in no change or possibly an improvement.

It's not a case of "telling myself", Karen. Anyone can easily obtain the relevant studies and verify it for themselves.

"If you cut sensitive tissue off an organ, there is less sensitive tissue, therefore the organ becomes less sensitive." -- that's a rather simplistic way of looking at it. Bear in mind that sensation is the product of sensitive tissue and stimulation; thus, to understand the effect of circumcision we must also consider the mechanical changes that take place and their effect on stimulation. It is generally recognised that, during at least part of the motion of intercourse, the foreskin covers the corona of the glans (and often part or all of the glans), reducing the amount of stimulation it receives. Consequently, as a result of circumcision, the glans receives more and more direct stimulation, increasing the amount of sensation.

"The PE and ED rates associated in areas that circ are greater than in the areas that don't. This is based on the amount of ED meds sold in countries that circ as well as the complaints of the sufferers.." -- Such vagueness is hardly evidence. I think you'll have to do better than that, providing detailed evidence and compensating for, for example, health care systems that result in high sales of all pharmaceuticals.

The only person who can legitimately say whether the change in sensation caused by cutting off a normal prat of a man's penis would be good or bad is the man himself. It is his body. It is his penis. It should be his decision whether or not to cut part of it off since there is NO compelling medical reason for the surgery.

"That's where you got it wrong, Jake. The glans is not the most sensitive area of the penis, several areas within the foreskin are more sensitive." -- I'm afraid you're mistaken, Karen. There is a (disputed) claim that the foreskin is part of the penis most sensitive to light touch, but that's not what we're discussing. In terms of the sexual sensitivity, the foreskin is the least sensitive part of the penis. I refer you to the work of Schober et al: Schober JM, Meyer-Bahlburg HF, Dolezal C. Self-ratings of genital anatomy, sexual sensitivity and function in men using the 'Self-Assessment of Genital Anatomy and Sexual Function, Male' questionnaire. BJU Int. 2009 Apr; 103 (8): 1096–103

"Circumcision bares the glans, which in time reduces its sensitivity." -- an old myth. Almost every study has shown this to be untrue. Eg.: Masters WH, Johnson VE. Human Sexual Response. Boston: Little, Brown & Co 1966: 189-91. Bleustein CB, Eckholdt H, Arezzo JC, Melman A. Effects of circumcision on male penile sensitivity. Paper read at the American Urological Association 98th Annual Meeting at Chicago Illinois, April 26-May 1, 2003. Publishing ID 1260, Abstract ID: 100769. Bleustein CB, Fogarty JD, Eckholdt H, Arezzo JC, Melman A. Effect of neonatal circumcision on penile neurologic sensation. Urology. 2005 Apr; 65 (4): 773–7. Payne K, Thaler L, Kukkonen T, Carrier S, Binik Y. Sensation and sexual arousal in circumcised and uncircumcised men. J Sex Med. 2007 May; 4 (3): 667–74

OK, yes the American Urological Association are the experts in this area but really aren't they profiting from this procedure which makes any recommendation by them unethical?

I'm sure you know as well as myself and other men that you don't need touch receptors to be sexually aroused or stimulated. You don't even need a foreskin to be sensitive to touch; however, it does not mean that the removal of the foreskin doesn't take away sensory perception that heightens the sexual pleasure for the man. There is no loss of touch receptors on the shaft itself (as long as it's done *properly*) but touch receptors do not necessarily mean sexual stimulation.

Regardless, sexual perception is an adult issue and not one for infants. We do not need to be doing this procedure on infants to *help* with a male issue. If an adult male wants to cut themselves... whatever. At least allow that adult to make the decision for themselves on their own body.

"OK, yes the American Urological Association are the experts in this area but really aren't they profiting from this procedure which makes any recommendation by them unethical?" -- I'm not quite sure of the relevance of your question, as we're not discussion their recommendations, but as a general point I think it would be rather an extreme stance to suggest that it's unethical to recommend something that might be profitable to oneself. That would have rather absurd consequences, after all: can you imagine a plumber standing knee-deep in water, unable to say anything because he'd profit by repairing the broken pipe?

"I'm sure you know as well as myself and other men that you don't need touch receptors to be sexually aroused or stimulated." -- I think you'll find that you do need touch receptors to be physically stimulated, though not necessarily light touch receptors.

"You don't even need a foreskin to be sensitive to touch; however, it does not mean that the removal of the foreskin doesn't take away sensory perception that heightens the sexual pleasure for the man." -- nor does it imply that it does...

First off, if a plumber is standing in water and says the pipes need to be fixed might not do anything because the problem wasn't necessarily investigated. Water is a symptom. The basement in my home is dirt - water is normal. For him to force me to fix pipes when the pipes aren't really the problem is unethical.

AUA would be unethical in its approach if they hype a problem in order to gain business - especially when there is no medical . Medicine is a business of course. These studies are their way of marketing to the medical establishment. It's like Big Pharma creating need for the product. It's like Big Oil creating shortage in order to inflate prices. Same deal.

"you do need touch receptors to be physically stimulated" I'm not an expert in the sensory department and CNS ability. I'm more of a microbiology guy.

"First off, if a plumber is standing in water and says the pipes need to be fixed might not do anything because the problem wasn't necessarily investigated. Water is a symptom. The basement in my home is dirt - water is normal." -- let's make the working assumption, for the sake of argument, that the reason why he's up to his knees in water is that a pipe has ruptured.

"For him to force me to fix pipes when the pipes aren't really the problem is unethical." -- agreed, but that doesn't mean that it is *automatically* unethical for him to recommend repairing pipes.

"AUA would be unethical in its approach if they hype a problem in order to gain business - especially when there is no medical . Medicine is a business of course. These studies are their way of marketing to the medical establishment." -- sorry, you're not making any sense. You left the first sentence incomplete, and you haven't specified which studies you're talking about.

"but that doesn't mean that it is *automatically* unethical for him to recommend repairing pipes." No not automatically... but he would be unethical if he couldn't prove the pipes were the problem.

" you haven't specified which studies you're talking about." I probably meant to say that there is no medical necessity. What proof do I need to provide? I'm not citing anyone's research or published material. I don't need to prove that medicine is a business. Isn't that what these studies do: sway opinion? Encourage practitioners to accept what they've found? I'm just reminding people of that fact of public knowledge.

"No not automatically... but he would be unethical if he couldn't prove the pipes were the problem." -- I'm not sure if I'd agree with the requirement for *proof*, though I'd certainly agree that he should have good cause to believe that they are.

"I probably meant to say that there is no medical necessity" -- no, you specifically discussed (unspecified) studies authored by the AUA. See the middle paragraph of your post dated 8:34pm on Sunday, May 1, 2011.

Well, to give a business person money just because that person says there is a problem is kinda foolish.

My statement is: "AUA would be unethical in its approach if they hype a problem in order to gain business - especially when there is no medical" ... the last word probably should have been necessity. That aside, I didn't state anything that needed proof. It is my opinion. I didn't say AUA is unethical. I didn't say AUA does hype problems. I'm simply saying that **if** they do hype problems then they would be unethical.

"I read those studies already and they have been refuted." -- claiming that they've been refuted is not the same as providing a refutation.

"Your defense of circumcision is disturbing." -- that's the fallacy of appeal to emotion: describing your opponent's argument (or, in this case, existence) as disturbing does not in any way invalidate his arguments. The best you can hope for is to deflect attention away from them, but I'm afraid that isn't going to work. :-)

I also remember that Jake tried to get around the issue of sensation loss by trying to prove that after circumcision that nerves regenerate. His proof, some speculation by Xin et al that they do.

Never mind that this peculation failed to even mention WHAT they would regenerate into--thin air?

Such is the foundation that Jake wished to dismiss the lost sensations and sensitivity--idle speculation.

And this from a man who then argues over the most insignificant aspect of any and all questionable statistical studies.

"There you go again, Jake, with more misinformation. Obviously when a man's foreskin is cut off it has NO sensitivity." -- obviously, though that doesn't imply that the net effect is a reduction in sensation, for reasons already explained.

"The authors of the study wrote [...]" -- Since they excluded the foreskin from their statistical analysis there would be no point in referring to the results of that analysis. I referred instead to their data.

The only person who can ethically say whether or not the change is sensation caused by cutting off a normal part of his penis has value is the man himself. That is NOT a decision that parents can ethically make for their sons.

Jake: "I referred instead to their data."

The authors did not publish their data. All they published was one graph which does not separate the responses of the men with intact penises from the responses of the men without intact penises.

When you cut off a normal part of a male's penis, he will never get sexual pleasure from that part of his body. No one, absolutely no one, has the right to deprive a man of a normal part of his genitals unless there is a compelling medical reason for the surgery.

"The authors did not publish their data. All they published was one graph which does not separate the responses of the men with intact penises from the responses of the men without intact penises." -- You're making the mistake of thinking that only numerical values are data. Actually, the ordered sequence presented in the abstract alone constitutes data, as do the four plots in fig 2. I'm somewhat puzzled by your reference to separating responses; while it is true that this separation did not occur, it is difficult to see why that should matter.

You continue to ignore the ethical problems associated with cutting off a normal, healthy part of a male's penis without his consent and without a compelling medical reason.

Without separating the responses there is no way of knowing what the 11 men with intact penises thought of their foreskin compared with other parts of their penises.

"You continue to ignore the ethical problems associated with cutting off a normal, healthy part of a male's penis without his consent and without a compelling medical reason." -- I don't believe that there are ethical problems, Stan. That's not the same thing as ignoring them.

"Without separating the responses there is no way of knowing what the 11 men with intact penises thought of their foreskin compared with other parts of their penises." -- the study didn't ask that question. The men weren't asked to compare or rank body parts as such. Rather, they were asked to rate the responsiveness of each part on a scale. The average ratings certainly permit comparison, however, and it is fairly clear that the foreskin was the least sensitive part of the penis in terms of producing sexual pleasure. The fact that relatively few men were uncircumcised limits the precision of this value, but it should not bias the value in one direction or another.

No ethical problem with cutting off a normal part of a healthy boy's body for cultural reasons without a compelling medical reason? You can't be serious!

To claim that the foreskin is the least sensitive part of the penis based on the opinions of 11 men is absurd! At best it is anecdotal evidence and it is contradicted by many intact men who say that their intact foreskin gives them more sexual pleasure than other parts of their penis.

The bottom line is no one can legitimately say whether or not a man's intact foreskin has value except the man himself.

"No ethical problem with cutting off a normal part of a healthy boy's body for cultural reasons without a compelling medical reason? You can't be serious!" -- perfectly serious, Stan. I've explained the ethical justification on many occasions.

"To claim that the foreskin is the least sensitive part of the penis based on the opinions of 11 men is absurd!" -- it's the best available evidence.

"At best it is anecdotal evidence" -- nonsense. Anecdotal evidence is inherently unreliable because there is no way of knowing whether it is representative or not. It is generated by self-selected persons, and recalled because it is interesting rather than necessarily representative (indeed, there's a general tendency away from the representative due to the fallacy of the striking instance -- unusual experiences tend to be more "interesting" than typical ones). This study is of an admittedly small number of uncircumcised men, and that is certainly a weakness, but it is a long way from anecdotal.

Culture and tradition can blind people to injustice. Cutting off a normal, healthy part of another person's body without their consent and without a compelling medical reasons is an injustice.