This is a revised copy of my manuscript, submitted for consideration of publication in The Skeptical Inquirer. The Skeptical Inquirer is the main publication of the Committee for Skeptical Inquiry, abbreviated as CSI (formerly known as CSICOP, for Committee for Scientific Investigation of Claims of the Paranormal).
One note about the title: Yes, I am aware that way the term “naturalistic fallacy” is used here is not technically accurate. (See here for further discussion). That’s why I preface it with the phrase “so-called”. In any event, only a tiny number of pedants know the corect meaning of the term anyway.
The Health Benefits of Circumcision: The “Naturalistic Fallacy” gets the boot.
Now that the CSI has officially expanded its role beyond the limits of the paranormal, it’s time to explore other issues where bogus and utter pseudo science prevails against the best legitimate science. One such area is the medical topic of circumcision and its health benefits.
The overwhelmingly popular, politically correct position on male circumcision has for decades been that the procedure is of little or no medical value and that the proper position is to prefer the “natural” alternative. But as we’ve seen in other areas of medical and health issues where “natural” is the favorite buzzword of popular rhetoric, “natural” is not always the healthiest choice. After all, HIV is perfectly natural, but being infected with HIV is surely no one’s idea of healthy living. Tornadoes and hurricanes are natural, too. Ogden Nash perhaps said it best when he observed: “Smallpox is natural; vaccine ain’t.”
While surely the overwhelming majority of us who read S.I. consider natural ecosystems and most other natural systems to be far preferable to at least poorly implemented artificial substitutes, in the field of health care specifically, there are most emphatically numerous improvements upon nature – especially treatments and cures that specifically attack key natural processes of various pathogens, such a vaccines and other prophylactic measures.
The standard position you’ll find on television, the web, parenting magazines, and books is the seemingly sober view propounded by the American Academy of Pediatrics in 1999 that there is little or no benefit to circumcision on health grounds. Even as distinguished a medical expert as Dr. Stephen Barrett, a CSI Fellow, has stated that, although he personally believes in evidence in favor of the health benefits of circumcision, he does not wish to update his site to reflect a disagreement with the AAP, which he still claims reflects the scientific consensus. [sup]1[/sup] His much more up-to-date and more topically knowledgeable peers strongly disagree. Consider, for example, just the recent words of Dr. Joseph D. Dickerman, who writes in the May 5, 2007 edition of the journal Pediatrics:
He also points out that the current AAP position cites six evidentiary reviews in favor of circumcision and only one minor review of extremely slight risk of the procedure (0.2-0.6%). Why hasn’t the AAP let science lead on this issue? In a word: politics. The anti-circumcision lobby is extremely powerful and has raised their voices to a fever pitch against anyone who does not conform to the anti-circ dogma.
The AAP’s position is completely belied by the best and latest medical evidence and should be overthrown, potentially saving millions of lives. The key issue here is that many pediatricians have far too narrow a scope of interest: it would appear that if the health benefits of circumcision do not seem to them to be overwhelming for a male infant or young child, then they’re not sufficiently interested in further data. They may find it outside of their domain of interest and their area of specialty. This seems, based on the surprising lack of willingness to address the issue in a fully and up-to-date scientific manner, to be true even if it potentially means death for a post-pubescent male. It would appear that these AAP pediatricians, with their emphasis on small children rather than adults, are simply the wrong group to consult.
The overwhelming source of pseudo-scientific and anti-scientific assertions that lay claim to by far the largest audience is a pseudo-scientific hodge-podge of often conflicting views propounded by the self-described “anti-circumcision” movement. This group does include legitimate doctors and scientists, but then so do the still-active HIV denialists like Dr. Peter Duesberg and others. So-called “Cold Fusion” and 9/11 conspiracy advocates also include many legitimate scientists. All we can conclude from this is that some legitimate scientists may be found in any advocacy group. We cannot conclude from that fact that all advocacy groups are thereby presenting legitimate science. And the best case in point of bad science from seemingly legitimate sources is the anti-circumcision movement, including groups such as Nocirc.org, CIRP.org, and the – dare I say - oxymoronically named “International Coalition of Genital Integrity” (ICGI). And let’s not forget other ostensibly responsible anti-circumcision advocacy groups with sane-sounding names such as “RECover A Penis” (RECAP) and “End the Horror of Infant Circumcision” (ETHIC).
For those of us who have the type of sense of humor that appreciates what Rev. Ivan Stang, a founder of the laugh-at-yourself pseudo “religion” called The Church of the SubGenius, refers to as “bulldada” – material that is so unintentionally moronic or outrageous that it’s hilarious – the anti-circumcision cults provide a truly rich vein of such wonders.
One example comes by way of anti-circumcision advocate Frederick Leboyer, M.D., author of Birth Without Violence, who wrote in a letter:
Then there’s this from Rev. Carles C. Messick III, H.P.:
Indeed, there is a very rich treasure trove revealing the emotionalism behind the anti-circumcision lobbyists and position, but I’m certainly not suggesting that all or even most of their rhetoric is this outrageous. Far from it! If it were, there’d be no need for this article. No, the overwhelming majority of the anti-circ movement uses professional, sane, and even quite appealing scientific language and arguments. And therein lies the rub. It’s very difficult for the average reader, such as a parent-to-be, to make sense of the conflicting claims and counter-claims when the language looks so similarly respectable and the AAP still prints obsolete and mostly irrelevant position papers as if they represent the best and latest evidence. If the skeptical reader hasn’t noticed the apparent empiricism, the frequent verbal shine, and the careful scientific-sounding discourse of paranormal groups provided by, for one example, The Journal Of Scientific Exploration [sup]4[/sup], then I encourage that reader to explore them. It can be most instructive.
Let’s take a brief tour through the anti-circ claims and see how they stand up to modern scientific thinking.
There is the “argument from evolution”, for example; it’s a form of the so-called “naturalistic fallacy”. The anti-circ people tell us that since we evolved with a foreskin, the foreskin is “natural” and thus “good” and “preferred” by natural selection. But all similar arguments are rather weak in that evolution also brought us through natural selection to be victim to all sorts of natural processes that actively harm us and shorten our lives. If evolution was looking out for “our” best interests, we’d have two hearts, our limbs would have longer moment arms (physics), and far more resilient telomeres that didn’t allow our DNA to unravel so terribly quickly, causing us to age and die at a ridiculous speed. Furthermore, the forces of natural selection “gave” us and our mammalian ancestors foreskins during our vast pre-historical childhood, probably to protect our helpless, naked glans from being injured by rocks and plants and forestation. But the foreskin has always been a near-perfectly welcoming incubator for all kinds of infective agents, not to mention certain other unmentionable items. Yet during our evolutionary childhood, we’d die so soon that the minor protection of the glans was more important overall, since reproduction was more vital for the survival of your genes than staying alive 20 years or so which would allow the infections to get more of a chance to kill you. But what informed male would side with that half of the equation today? In short, evolution has harmed us, not benefited us in this respect. It’s just that at the time, the “solution” worked acceptably well. It does so no longer.
Then there are claims that, although the uncircumcised penis can be an awful source of odor and other unhygienic unpleasantness, it is easy to clean and that this solves this problem simply. All I can say about this is that these advocates either spend an inordinate amount of time in the shower or don’t follow their own current advice. Not to mention the fact that they probably never closely checked up on the hygienic procedures of the uncircumcised sons of their own.
In truth, studies show that most boys and young men just do not follow a penile hygiene plan with any care at all, and it actually gets worse as the boy matures. [sup]5[/sup] And let’s note that that a very large number of men can’t or don’t bathe often enough anyway.
Of course, the classic anti-circumcision canard is that a circumcised man experiences less physical pleasure than uncircumcised men. This is an extremely common assertion. It’s practically the backbone (as it were) of the entire movement. But is it true?
While the issue is certainly debatable (and will continue to be debated on purely emotional grounds long after science has answered the question more or less unequivocally), most of the data I’ve read have indicated just the reverse is true for most men who are in the best position to judge: men who have been circumcised as adults. In fact, some men complain that after their circumcisions, the pleasure is too strong! This is likely because formerly, their glans was usually or even always covered in large part by their foreskin (some foreskins never retract completely, even during sexual relations), but when it was removed, the sensitive glans was over-stimulated compared to their prior state. The exposure of the edge of the glans is of paramount importance to sexual pleasure, thus hiding it under the foreskin should logically, and almost certainly does, result in less net pleasure.
So the burden of proof should, I contend, be turned around. It is the uncircumcised man who probably feels less physical pleasure, although truth be told, the experiences of the two types of men are in some ways too different to draw final conclusions.
Some also argue that parents should not make the decision for their sons. This is trite and misguided, to say the least. What other vital health decisions would anyone argue that parents forgo for their infants? Isn’t a major part of their very purpose in life to make such early decisions? This is particularly true for circumcision, because the maximum health benefits – such as near-perfect prevention of penile carcinoma, drastic reduction in urinary tract infections, and the serious scarring that often accompanies UTI – only accrue if the procedure is performed neonatally. It’s therefore harmful to your sons to wait for them to make the decision (which they’re not likely to even broach with you when they reach puberty anyway, thus forfeiting the decision to the parents after all). All we can say for sure is that a handful of sons will complain no matter which way the parents decide, but that’s no excuse for not choosing wisely when your son is an infant.
But my prime candidates for consideration here are the claims by the anti-circumcision mob that there are few to no health benefits from circumcision. And the bulldada comes thick and fast in that arena, let me promise you!
The first is the falsehood that circumcision provides no significant protection against penile cancer. Let me say right at the start that the incidence of penile cancer is very low in Western societies, but let me also point out that circumcision is an etraordinarily effective prophylactic measure against it. Let me further point out that it’s an odd man who would choose to knowingly increase his odds of having his penis amputated by such a huge margin for virtually no cost. In “The Highly Protective Effect of Newborn Circumcision Against Invasive Penile Cancer” (2007), Schoen, Oehrli, and Machin [sup]6[/sup] demonstrate that, of those with invasive penile cancer where the circumcision status is known, 97.7% of them were uncircumcised. Worldwide, Israel has the lowest number of cases while countries where circumcision is rare can see as much as 4000% higher incidences. In Uganda, penile cancer is the most common cancer among men, and it results in 17% of all malignancies in some areas of Brazil. [sup]7, 8[/sup]
But let’s move to my most vital point: In study after study up through the year 2007 so far, the overwhelming evidence is that circumcision provides a highly effective – though imperfect – prophylactic measure against HIV infection.
Let me say that again: Circumcision enormously reduces the risk of contracting and spreading HIV and AIDS.
If we were a rational civilization, that would end the debate. But surely I need not remind the reader of S.I. that we’re not living in a rational world.
Let’s look at the data.
Here’s a selection from a 2007 article by Dr. Helen Weiss entitled: “Male circumcision as a preventive measure against HIV and other sexually transmitted diseases”:
Keratinization in this context refers to the very slight thickening of the skin and glans of the penis that results from circumcision. It significantly reduces the severity or even entirely prevents many diseases that otherwise affect the uncircumcised penis, such as penile carcinoma, HPV and other STDs along with HIV.
There are a great number of articles in the medical journals and in places like MedLine and PubMed that also report these and more favorable findings. In previous years, careful cohort studies in San Francisco reported an 800% reduction in the likelihood of HIV infection among circumcised gay males and their partners whose behavior closely paralleled their uncircumcised cohorts, with similar results in New York City.
And the NIH reported that recent Ugandan and Kenyan studies were suddenly ended prematurely when the overwhelming benefits of circumcision became so obvious that ethical principles demanded that they make the procedure available to everyone in the study. [sup]10[/sup] Many of the anti-circ crowd deny all of these scientific facts, as pseudo-scientific cults are wont to do. Some claim that these results won’t be reflected in the United States and other advanced Western countries, but that, too, is so much bulldada. Not only do the San Francisco and New York cohort studies which found an enormous protective effect against HIV infection still stand, the CDC has also come down on the side of reason and advocated greater consideration of circumcision in the United States. The CDC stated that the very recent result of studies in high-risk men, the adjusted relative risk was at least 71% lower for circumcised men! They write: *“A few men who had been assigned to be circumcised did not undergo the procedure, and vice versa. When the data were reanalyzed to account for these deviations, **men who had been circumcised had a 76% reduction in risk of HIV infection *compared to those who were not circumcised.” [sup]11[/sup]
But anti-circ folks continue to desperately claim these data are not relevant to the United States. And the CDC has an answer for them:
My fellow Straight Dopers and Skeptical Inquirers, we’re talking about a prospective 350% increased risk for HIV in uncircumcised men! Only pseudo-science can explicate the continued carping of the anti-circ circus.
(conclusion and references in next post)