Thursday, September 13, 2012

Response to Harriet Hall on her article on Science Based Medicine about circumcision

Harriet Hall publised in "science based medicine" an article about "the new AAP Policy on circumcision". In that article, she makes reference to a previous article she wrote in 2008, called "Circumcision: what science says".

In her new article she takes the task to respond to the response from the Circumcision Resource Center to the AAP. the CRC responded with 20 bullet points, and Mrs. Hall comments in some of them, leaving to her readers to "spot the fallacies in the rest".

I felt the need to respond to her response to the response to the CRC.... (you get the drilled). In the middle of it, I realized that in her 2008 article she patronized the men who feel that their circumcision was a forced mutilation, by stating that "If some men are psychologically damaged by circumcision and mourn their lost foreskin, their mental health must be pathologically fragile. Get over it, guys!". She further tried to shame men with a sex-negative comment on how the "foreskin is required for the homosexual practice of “docking.” ". How is that relevant? The foreskin is also useful during intercourse, oral sex, masturbation, but how can we know that, if we had it stolen during our infancy?

How does it feel to be raped while you sleep? How does it feel to have something stolen while you are away? Does that make the rape or the theft any less real?

But let me skip my emotional response for a moment. I wrote a response to the 20 points which she objects as fallacies. So:

Mrs. Hall,

You left your readers the task to spot the fallacies in the rest of the 20 points. Did you forget to leave the exercise to spot your own fallacies?

Let me start by saying that you acknowledged that there are 2 extreme sides to this discussion, one where circumcision of male infants could be seen as child abuse and a human rights issue, and one where it can be seen as a preventive and prophylactic medical procedure. A Task Force evaluating a policy on circumcision should be able to discuss rationally both extremes, because the conclusions should come from this discussion.

Let me also state that medicine is not just science, but also needs to be humane as it deals with the well being of human beings. For example, when a person suffers certain conditions, scientifically it may make more sense to let her die or to help her die, but from the humane point of view a doctor cannot take such a decision. A doctor should provide good treatment in the measure that the person is willing to accept that treatment.

On point 1 you said: "they say all that is needed is feelings and common sense". While the point was poorly explained, your simplification was worse, so let me put it in perspective.

There is no denying that circumcision is an amputation. Most amputations are only done on a need basis, i.e. when the organ to be removed is so diseased or damaged as to represent an immediate threat to the health of the person. This is in order to provide a conservative treatment that respects the dignity of the person. Amputations are rarely done in as prevention, and in those cases, it's usually when the risk is immediate for that person, for example a woman who has cancer in one breast and undergoes mastectomy, might choose to have the other breast removed if there is significant risk of developing cancer on it as well.

When considering an amputation, it's always good to consider if there are alternatives of treatment, since any part of the body that is removed will have some effect and won't be replaceable.

However, circumcision of babies is not performed because there is an immediate risk from the foreskin, as the foreskin is healthy. And quite often, any potential benefits can be also attained through different procedures. Some benefits would only exist if the person was to later develop a condition, for example preventing phimosis only makes sense if that person is one of the few that will develop phimosis. Routinarily removing tissue to prevent such a condition equates to treating what has not happened, because circumcision is not an immunization for those conditions, but a last resource treatment for those conditions.

Removing any organ removes the functions of that organ.

That's why circumcision is seeing as harmful genital surgery.

On point 2, you again oversimplified it by summarizing to say that members of the committee (task force) were biased because they were circumcised or had performed circumcisions. Conveniently you didn't mention religious or cultural bias (which are mentioned in point 2 of the document you are discussing). Let's see:

Susan Blank, Jewish, has helped mediate between the city of NY and the Jewish community in the case of the babies that contracted Herpes due to a Mohel performing the oral suction on babies, which caused at least two deaths and one case of brain damage. It would be hard to not see that she has a religious bias to a faith that considers circumcision central to its practices and identity.

Andrew Freedman, Jewish. Circumcised his own son (which on its own is ethically troublesome per the AAP), acknowledges that he didn't do it for any medical benefit but to keep his tradition alive. He also acknowledges that a 20% of his patients will see him for reasons related to their circumcisions. Definitively biased.

Doug Diekema, of Calvinist background. Posts jobs openings for bioethicists on Jewish websites. Twice advocated for a "ritual nick" that would be performed by pediatricians on female minors as an alternative for families from places where FGM is prevalent even though such a procedure is prohibited by Federal Law. Not only a person with religious bias, but also a person who in an interview in another controversial case (the Ashley case) stated: "There are always people who will claim we're playing god. We -- we can't help but play god in this world and in medicine. Every time we intervene in the course of patient's care, we're playing god. "

So these are 3 out of the 8 members of the Task Force. They seem pretty biased to me. Remember how I said that a Task Force should be willing to evaluate both sides of the argument, that circumcision could be a violation of human rights or medicine? Well, do you think that these 3 people would be fit to discuss circumcision as a violation of human rights and as a form of genital mutilation? I don't.

3. Other countries recommend against circumcision. This is indeed important. They have access to the same studies, the same science. Why haven't they reached the same conclusions? Why do they discourage the practice, or completely ban it? That would surely deserve some research. Or is it that after 150 years of practicing "medical" circumcision, we are so desensitized to it that we just need to justify the perpetuation of the practice rather than evaluate if it really doesn't make sense anymore?

4. This point is fascinating and deserves extended notes. For one, along with the 3 randomized trials from Uganda, Kenya and South Africa which showed the relative reduction of 60% (meaning real reduction of just a bit over 1%), studies from other African countries in the same time showed different results, including more prevalence among circumcised people and lack of prevalence. However, the WHO, UNAIDS and the AAP have preferred to blindly follow the 3 randomized trials. The WHO and UNAIDS make more sense as they promote an intervention in the studied territories. But those results are not necessarily applicable to the U.S. (and the technical report recognizes it) but yet they still promote it as the new big benefit of circumcision. Perhaps the disparity in studies (including a recent one from Puerto Rico and another from the NAVY, the first one showed more prevalence of HIV among circumcised men and the one from the NAVY didn't show correlation), comes from the fact that the practice or not of circumcision is not the controlling variable, but the customs, cultural and religious practices of people.

5. The report doesn't say the word condom. Which is true. Consider that many of the benefits have to do with preventing STDs especially the infection of HIV. As I mentioned earlier, before performing an amputation you should consider the alternatives of treatment. An uncircumcised man, as part of safe sex, should use condoms. A circumcised man still has to use condoms. So, wouldn't it be clear that it is more important to educate the kids to practice safe sex, rather than amputate tissue from them and expect that they will learn to practice safe sex on their own?

6. You criticize the statement about penile cancer by indicating that they compare data from two different countries with different rates of circumcision. Isn't that the same that the AAP does when they compare the 3 randomized trials of Uganda, Kenia and South Africa, with the United States, to come up with this new benefit of HIV prevention?

More important, the factors of risk of penile cancer include phimosis during adulthood, HPV, smoking, UV light treatment of psoriasis, age over 68 and weak immune system. In general, circumcision only takes care of phimosis, and it is said that it reduces the risk of HPV. Phimosis however, when present in adulthood, can be treated in less invasive ways, and HPV can also be prevented with the use of vaccines in both males and females. So those two things combined will eliminate the need to perform an amputation as prevention for penile cancer.

Penile cancer is also a very low risk. 1 in 100,000. However, the AAFP estimates the rate of deaths from circumcision to be 1 in 500,000. Which means that in order to legitimately prevent 5 cases of penile cancer in old age, one baby may have died.

The Cancer Society states that most experts agree that circumcision should not be recommended solely as a way of preventing penile cancer.

7. The decrease in UTIs is minimal and they can be treated with antibiotics. Again, this is where we should consider alternatives of treatments before performing an amputation. Not every baby will develop UTIs. In general, girls have more risks of UTIs than boys. The preventive effect of circumcision on UTIs is considered to be during the first year of life.

So, to prevent something that may or may not happen during the first year of life and that can be easily treated, we are instead promoting an irreversible amputation.

8. Preventive benefits are not actual health benefits. Well, you have to balance the supposed benefits compared to the risks, to the damage, and to the loss from the procedure. If you get sick and a treatment heals you, that is a benefit. If you get an immunization and as a result you don't contract a disease, that is a benefit. If you get an amputation to partially prevent some diseases, you are also losing something and you are also receiving a harm. So the equation is not as clear that the "potential benefits" are such real benefits.

9. Pain. Yes the report mentions anesthesia. While there has not been a formal study, there are some indications that circumcision and the pain from it cause changes in the patterns of the brain, based on an informal MRI of a baby during his circumcision. Again, unfortunately no further studies have been performed in this area. This point also states that some babies don't cry because they go in shock. This does not refer to circulatory shock as you said, but to neurogenic shock from the psychological trauma.

10. Yes the technical report mentions ethics, but does a weak job of it, never discussing whether circumcision of minors is a human rights issue at all. The big question that the technical report fails to answer is whether it is ethical to amputate healthy tissue that is not suffering a disease or posing an immediate threat to a person, as perhaps a preventive or prophylactic intervention, authorized only by parental consent, when such a procedure also exposes the child to certain risks and certan harms and the loss of certain functions. You won't find an answer to this question in the technical report.

The section about ethical issues of the technical reports states that "In most situations, parents are granted
wide latitude in terms of the decisions they make on behalf of their children, and the law has respected those decisions except where they are clearly contrary to the best interests of the child or place the child’s health, well-being, or life at significant risk of serious harm.10". This already implies that the technical report should consider whether circumcision is contrary to the best interest of the child or places the child at significant risk of serious harm. This should be clearly elaborated.

It continues: "Reasonable people may disagree, however, as to what is in the best interest of any individual patient or how the potential medical benefits and potential medical harms of circumcision should be weighed against each other.". This equation is already out of balance. You don't only have potential benefits and potential harms (risks), but you have real harms (the damage that always occurs, i.e., keratinization of the glans, loss of the functions of the foreskin), and potential benefits of not being circumcised. Those two last items are not even considered in the report.

The report follows: "This situation is further complicated by the fact that there are social, cultural, religious, and familial benefits and harms to be considered as well.12 It is reasonable to take these nonmedical benefits and harms for an individual into consideration when making a decision about circumcision.13" These exact words could be used to justify another practice that is indeed federally prohibited in our country: Female Genital Mutilation, which is part of some social, religious and cultural groups and provides some non-medical benefits (such as eligibility to marry within the cultural group, a religious "honor" as stated by a mother in Malaysia, etc).

The following paragraph, in a parenthesis, mentions the cases "where the procedure is not essential to the child’s immediate well-being". This point is most enlightening. Non-therapeutic circumcision is not essential to the child's immediate well being.

It continues: "In the pluralistic society of the United States, where parents are afforded wide authority for determining what constitutes appropriate child-rearing and child welfare, it is legitimate for the parents to take into account their own cultural, religious, and ethnic traditions, in addition to medical factors, when making this choice". Again, this argument could also be used to justify FGM, which is not surprising given Dr. Diekema's previous attempts at justifying the "ritual nick".

Another paragraph states that "Parents may wish to consider whether the benefits of the procedure can be attained in equal measure if the procedure is delayed until the child is of sufficient age to provide his own informed consent." This has been my point so far, not only the potential benefits can be attained waiting, they can also be attained through alternative procedures. They however follow: "Newborn males who are not circumcised at birth are much less likely to elect circumcision in adolescence or early adulthood." This statement alone should be considered an important indication that most men, on their own, would not choose to be circumcised. So why would the parents force this upon them?

I found funny, but just another display of the religious bias, this statement: "The Task Force advises against the practice of mouth-to-penis contact during circumcision". In ANY OTHER context, an adult person placing his or her mouth on a baby's penis would be committing sexual abuse on a minor. However, because this happens in the context of a religious practice, it is tolerated. This practice should be denounced. Religious freedom cannot justify harming any person. NY Mayor Bloomberg said in reference to this practice: "religious liberty does not simply extend to injuring others or putting children at risk". But this practice not only puts children at risk, but makes them victims of a sexual abuse, whether they remember it or not. As an analogy, rape is rape whether the victim is conscious or unconscious.

But to round this argument, all these paragraphs never answered the real ethical question, whether it is ethical to amputate healthy tissue that is not suffering a disease or posing an immediate threat to a person, as perhaps a preventive or prophylactic intervention, authorized only by parental consent, when such a procedure also exposes the child to certain risks and certan harms and the loss of certain functions.

Point 11 on coercion and unauthorized circumcisions is actually important. In September 2010 the Delgado Family in Miami had their son circumcised against their expressed intentions. The hospital said it was a mistake. The baby was in intensive care (so we can speculate that his health was not great), the family had expressed that they didn't want circumcision, and yet he was taken to circumcise in the absense of the mother. The mother sued for battery. In a different case, William Stowell in 2000 sued the hospital that circumcised him at birth arguing that his mother was under the effects of anesthesia when she signed the consent form. The lawsuit was settled for an undisclosed amount.

Point 12, hygiene. There is no discussion on this issue, except to state that the report's description of the care of the uncircumcised penis is vague and improper. The "adhesions" (synechia or balano-preputial membrane, two names absent from the report) do not necessarily resolve in the first 4 months of life, some times taking until after puberty. Suggesting that "When these adhesions disappear physiologically (which occurs at an individual pace), the foreskin can be easily retracted" sounds too much like an invitation for parents to probe whether the foreskin is retractable or not after the 4 months, which is very likely to result in wounding and bleeding in the synechia, development of scar and infections, and finally development of acquired phimosis which is likely to require medical circumcision. Nobody should retract the kids foreskin, not the parents, not the doctor. The parents should wash the penis as if it was a finger, only the outside. Only the kid should retract the foreskin and only when he can do it comfortably.

Point 13, actually it does not mention the functions of the foreskin. After reading your argument I read the technical report one more time. Nada. And even though Sorrell's study on Fine-Touch Pressure Thresholds in the Adult Penis is referrenced in the technical report, they dismiss the conclusions of this study which is that the most sensible parts of the penis are removed by circumcision. Interesting enough, that part is called "rigged band" and is not mentioned in the report at all. The "frenulum" is not mentioned either. The report never refers to circumcision as an "amputation", reserving the word "amputation" to cases of amputation of the penis or the glans. It does refer to circumcision as "excision". Oh and the document "Neonatal Male circumcision global review" of UNAIDS mentions Sexual dysfunction as one of the risks of circumcision.

Point 14, if you do some searches you will find that since 2010 the question of whether circumcision is related to ED has been in the internet. In 2011, Dan Bollinger presented a study that found a 4.5 greater chance of ED in circumcised men. This study however falls out of the 2010 cut out range for literature covered by this policy. Anticipating point 17, this is one issue that deserves more research.

Point 15, psychological harm. I would invite you to visit the existing forum on foreskin restoration to find many men who report psychological and physical harm from circumcision. Apparently these men have not attracted the attention of researchers. In your previous article you wrote: "if some men are psychologically damaged by circumcision and mourn their lost foreskin, their mental health must be pathologically fragile. Get over it guys!". Not only you acknowledge that there might be men who are psychologically damaged by circumcision, but you proceeded to insult and patronize those men. Would you think that women who mourn a lost breast to mastectomy have pathologically fragile mental health? Or women who suffer the trauma of being raped? Well, why do you think that men should get over it?

Let me explain you something. When you steal something from a child, the child may grow into an adult, but it's the inner child who will always remember that something was taken from him. Not all men who are circumcised go through this, but it is undeniable that many men do. And this won't go away just because you say "get over it" with an exclamation sign.

This is a real issue. I've seen terrible anger, sadness, depression. They were the patients of 20 and 30 and 40 years ago, who are suffering the consequences of their procedure. A procedure that they DID NOT ELECT, in spite of being an elective procedure. It is the ethical and moral duty of the AAP to study this, to pay attention to this phenomenon. Men have been quiet for too long, but thanks to the internet they managed to leave the shame and speak out and realize that they were not alone in suffering. This is valuable.

If the AAP does not correct this path, we are going to see more men psychologically damaged in 20 and 30 years from now. Those are the kids that the AAP is failing to protect, and that you patronized carelessly.

I don't understand why the medical community does not realize that they have been creating a problem. Honestly, this deserves a serious study NOW. I even get agitated writing this, because I have seen those strong emotions, I've seen those terrible depressions.

I often visit another page, Yahoo Answers, and find teenagers as young as 13 years of age, inquiring about the methods for foreskin restoration. Why do you think that teenagers are willing to subject themselves to the disconfort of years of restoration? Is this not a valid question?

Is the psychological damage or psychological trauma not part of the scientific domain? Really, I need to know. It boggles my mind the carelessness of the medical community in this regard.

You even tried to shame men by mentioning that the foreskin is necessary for the homosexual practice of docking. Sorry, that won't work. The foreskin is useful for many sexual practices, from masturbation to intercourse to oral sex to docking. J. H. Kellogg knew it and that's why he promoted circumcision to curb down masturbation. It didn't curb it down, but it made it less pleasant, even if the AAP now states that there is no difference. I have asked intact men, I have compared experiences. I have no doubt that the foreskin is the perfect complement to stimulate the glans, something that circumcised men like the doctors in the Task Force or like me, wouldn't know about normally. And something that most uncircumcised men will take for granted. Anyway, my point here was not to go back into the pleasure issue, but to say that the medical community owes respect to those men who perceive themselves as mutilated, and ought at least to investigate this issue in order to take any corrective measures to prevent this. That is their ethic duty.

I am going to stop here, but I just realize something. The point 10 is not the ethical issues. It's ethical objections. Basically it speaks of doctors and nurses who refuse to perform or assist circumcisions because of ethical considerations. This is something that is not mentioned in the report, and at this point I say that you didn't read properly point 10 and oversimplified it to turn it into another fallacy. Shame on you.

You say that the intactivists cherry-picked studies. Intactivists say that the AAP cherry-picked studies by ignoring, dismissing conclusions of some, ignoring contradictions between some. All of this in regards to the studies included as references in the Technical Report.

Just one thing. Every time that you are going to perform a treatment and that treatment may cause a harm, you really need to study those harms. Exhaustively. Beyond doubt. Otherwise, you are opening yourself to tremendous ethical and legal risks. Not calling for studies on the real damage and risks of circumcision puts the AAP in that position. Evidence of that attitude is given by the words of the AAP: "Financial costs of care, emotional tolls, or the need for future corrective surgery (with the attendant anesthetic risks, family stress, and expense) are unknown.". If it's unknown, shouldn't it be studied? That's what they were supposed to be doing.

It also says: "The majority of severe or even catastrophic injuries are so infrequent as to be reported as case reports (andere therefore excluded from this literature review)." How infrequent are they? Case reports need to be studied, or studies have to be based on them. When you don't know something and you need to form an opinion, well you need to study it, don't you?

Death is acknowledged as one of the more severe complications, but no attempts are done to present numbers or rate of mortality. The word "death" in that context is mentioned just one time in the report. Again, this is something that surely deserves further study. Nobody takes a baby to a prophylactic or preventive intervention expecting that their baby may die, especially when there was no urgent condition for that medical intervention.

Please reconsider the humane aspects of this issue, the human rights aspect of this issue. The world will be grateful to you if you do.


  1. I am circumcised and sex is okay. I was circumcised as an adult so I know both sides. Honestly, there has been some loss of sensitivity there is no question as oral sex isn't as good as it was before but in general I can orgasm naturally in fact if I move fast I cum too quickly so I think everything is ok. I fear, however, if I will lose more and more sensitivity and then I am pretty much fucked up. I hope it does not happen.

  2. I hope everything goes fine for you. Why were you circumcised as adult, if you don't mind me asking?

    If it was due to medical necessity, have you considered doing foreskin restoration?

  3. In the article Hall wrote in 2008 she claims repeatedly she is not pro-circumcision. Several times she provides links to CircList, a circumfetish site. She draws much of her material from a site which has numerous links to circumfetish websites run by a person who has strong ties to circumfetish organizations. Her list of arguments for intactness are distortions and parodies of reasoning actually used and in some cases pure inventions. i.e. a straw man argument.

    She comes across as condescending, callous and unethical.

    Pro-circumcision people in the comments section enthusiastically support her.
    Methinks she is a liar, she is pro-circumcision.

    I guess she has done lots of infant circumcision.