Scattered thoughts on circumcision

In the wake of a German court ruling that circumcision cannot be performed on a child who is too young to give consent, I thought I would share my thoughts on circumcision. This post will be broken down into sections to organize it a little, but I am not going to attempt to really weave it together into a coherent whole. Just some scattered thoughts.

My background

In the interest of full disclosure: I am circumcised. Both of my sons are not. Most (but not all) of my male peers are circumcised; most (but not all) of my friends with young sons have chosen not to circumcise. I'd like to think this is a generational thing, but while there is some data to support a shift, I think in my case it has more to do with selection bias, namely in the fact that a lot of my friends are into natural birth, attachment parenting, and related stuff.

The health effects

Well, there's a lot of conflicting data out there. My general read is that the risks and benefits seem to very nearly cancel each other out. Circumcision does seem to have some modest prophylactic effect against infection, some sexually transmitted diseases, possibly against a rare form of cancer, etc. Given the sociopolitical pressures to justify circumcision, I suspect this data might be exaggerated, but there does seem to be something to it.

This, of course, is weighed against the direct risk of complications from the procedure, which are rare but not unheard of. The upshot is that you are balancing a very small number against another very small number, and it is difficulty to say which is larger.

In any case, one thing we can be certain of is that the total effect on health is small, even if we don't know whether it is a net positive or net negative. With the possible exception of curbing transmission of HIV in areas experiencing an extreme epidemic, it does not seem that health effects alone are sufficient to indicate either for or against circumcision.

Update: I am glad I used the phrase "possible exception" in the above paragraph, as it has since come to my attention that there is good reason to doubt the claimed efficacy in terms of HIV transmission. The research that has been used to back this contention has some very serious problems (most egregiously, the circumcised groups received sexual health counseling that the control groups did not), and to further compound the matter, there are reports of circumcision being oversold to African men, even going so far as it being pitched as a "natural condom". Obviously it is a terrible HIV prevention policy if men are getting circumcised in lieu of using a condom!

The quality of life effects

This is something you don't hear a lot about outside of outspoken anti-circumcision circles. Part of that is because people tend to focus only on the health effects and cultural issues, but I think it's also partly because this is incredibly difficult to measure.

There are numerous anecdotes to suggest that circumcision has a negative effect on sexual pleasure, possibly for both partners. I employ my routine skepticism here, in that I generally am not willing to accept a conclusion based on anecdote alone, but the idea is at least plausible.

In short, there's not enough data here to really say much of anything... but the fact that this is at least a possibility ought to enter into the evaluation.

Consent

Here's where I agree, at least in principle, with the German court. It is possible based on what we've seen so far that there is a very small but real health benefit, and that there are no quality of life effects. My response: So?

It would seem that performing an invasive medical procedure that resulted in a rather drastic cosmetic change, without consent, for only a modest health benefit, violates the principle of primum non nocere. Even if there are no quality of life effects -- which is far from certain -- you're still performing a non-trivial body modification, and to do so without patient consent seems to be a cost that must be taken into account. And while that cost is not insurmountable, the modesty of any possible health benefit (if it even is a net benefit) does not seem to me to have any prayer of balancing it sufficiently.

In other words: In even the best possible scenario, the lack of consent argues against routine circumcision.

Culture, religion, and discrimination against an ethnic minority

This is where it begins to get a little tricky. Not so much in Israel or in Muslim countries, of course, but in countries where circumcision is a ritual practiced primarily by an ethnic minority. I don't really have much to say about it, other than that it's important to examine both others' as well as one's own motivations. It is undeniable that opposition to circumcision has, at sometimes in history, been used as a club to promote antisemitism and Islamophobia. And that's just not okay.

Harm reduction

So one can pretty easily tell from this that I don't think circumcision is a good idea. But what do I think about public policy? Do I agree with the German court? Should circumcision without consent be banned?

I'll give my answer in the final section, but first I want to point out that if circumcision were banned in the US tomorrow, it would put countless baby boys at risk. Why? Because there are thousands of Jews and Muslims who are simply not going to stop the practice, and if you make it illegal then they will find a way to have it done underground. The back alley abortion will be joined by the back alley bris. "I know a guy who knows a guy... I can vouch for you, but don't bring anything with you except the cash and the baby. These mohels will cut you!" (Bah-dump)

I joke, but this is deadly serious. If people are going to circumcise their infants, it's better that they get hospital care (or, if having a mohel do it in a home, at least know they can go to the hospital if necessary without fear of prosecution). This, of course, has to be weighed against all the people who presumably would not circumcise if it was not a legal option. But I have a partial remedy in mind for it...

Conclusion

So my wife and I choose not to circumcise, and I exhort others to make the same choice. But what do I think about public policy?

I would like to see it start with a very modest incremental step, which I think would drastically reduce the number of circumcisions taking place in the United States, while not creating any sort of undue burden on ethnic minorities nor creating any inadvertent dangers by way of driving the practice underground. It is simply this: Hospital staff should be legally barred from bringing up the topic of infant circumcision, unless there is a specific medical indication in favor of it. If a parent/guardian inquires about it, doctors and nurses are then free to discuss it without limitation, just as they are now.

It is impossible to quantify, but it seems highly likely to me that there are tremendous numbers of parents, in the US at least, who have their sons circumcised as a matter of course, not because they have strong feelings about it, but because they just assume that is what's done. They would presumably not seek it out if it were not offered, but if offered, they may simply check the "yes" box (figuratively speaking) without thinking about it. If we can only get these people to stop circumcising, that is a tremendous win, and could have a profound snowball effect against routine circumcision.

On the other hand, the most harm that can possibly result from such a policy would be that a family who was passionate about circumcising for cultural reasons might "forget" to ask about it, and would have to come back later. That would indeed be a nuisance, but it is a relatively minor one, and I imagine it would be relatively rare: most people who are passionate about it will simply ask their obstetrician at a prenatal appointment.

Many would argue that such a change would not go far enough. I don't necessarily disagree, but nevertheless I fear the specter of black market circumcisions, and in any case I think anything more drastic is simply a political non-starter right now. My suggestion would reduce routine circumcision dramatically, while enacting a tactical retreat in regards to religious tradition.