A critical analysis of Rebecca Dekker's "evidence based" circumcision article
Rebecca Dekker PhD RN, a nursing professor and founder of the Evidence Based Birth website, posted an article, "Evidence and Ethics on: Circumcision."  An FAQ states that the article provides "evidence-based information as clearly, completely, and objectively as possible... [W]e endeavored to leave our personal opinions out of this article on circumcision and highlight the voices of experts in the medical and bioethics literature." 
Guest contributor Melanie Lindwall Schaab MS RN wrote this comprehensive analysis. Schaab is a certified family nurse practitioner, a licensed midwife, and an admin for Circumcision Facts and Science, Dekker's statements are highlighted in blue, followed by Schaab's responses
Evidence and Ethics on: Circumcision
The United States is unusual in that the vast majority of newborn circumcisions performed in the country are done for non-religious reasons.
Actually, that's the standard for developed nations. Israel (Jewish) and Turkey (Muslim) are the only developed nations with high circumcision rates over the past century that perform the procedure primarily for religious reasons. Australia, Canada, New Zealand, South Korea, the United Kingdom, and United States all did it for medical reasons.
The United States had produced research on the topic of circumcision since 1855, when Dr. Hutchinson showed that circumcision had benefits.  But circumcision didn't really take off in the U.S. until after World War I, and again after World War II. Uncircumcised soldiers ended up with foreskin infections that required surgery, while circumcised soldiers were much better off. (British soldiers, who were largely circumcised at the time, were better off than their American counterparts.) When they returned home, many solders chose to circumcise their infant sons.  Americans continued circumcising in part because we've continued to be involved in wars and in part because of the research.
South Korea started circumcising after the Korean War for similar reasons. In the Korean War, American soldiers had fewer genital problems than South Korean soldiers. Circumcision took off and became very popular; most of those who don't get circumcised choose not to because they consider themselves "naturally circumcised" (very short foreskins, which is common among Asians). Today, South Korea (77%) has a circumcision incidence very similar to the United States (80%).
In the U.S., the overall rate of newborn circumcision is on the decline.
The newborn circumcision rate is determined by a National Hospital Discharge Survey (NHDS) data,  which underestimates newborn circumcisions by 15-25%. This figure also doesn't include circumcisions performed after hospital discharge (e.g., Jewish religious circumcisions) or those performed later in infancy for medical reasons. The adult circumcision rate is determined by the National Health and Nutrition Examination Survey (NHANES), which tells us the circumcision incidence in ages 14-59.
So we have an underestimate of newborn rates and probably an accurate estimate of the total newborn, child, and adult circumcision rates. Using that, we can extrapolate the approximate circumcision incidence for each age group. It dropped from roughly 82% for those born in the 1970s to 76% for those born in the 1990s. The newborn circumcision rate per NHDS in 2010 was 58.3%, which correlates to about 77.2% in adulthood. It constituted a tiny increase from NHDS 58.0% in 2000-2009.
We can anticipate that the rate will continue to rise because of the pro-circumcision position statements by the AAP in 2012  and the CDC in 2018.  We can anticipate a rise also because several states have restarted Medicaid newborn circumcision coverage.  (Rates are 24 percentage points higher in states where Medicaid covers the procedure.)  Nevertheless it's true that the average today (58.3%) is lower than the average in the 1970s (64.5%). Because the difference is small, most researchers say the rate has been steady, not that it is declining. 
bodily integrity (removing significant tissue from an intact sexual organ without consent)
Joseph Mazor, a British bioethicist who is not himself pro-circumcision, previously argued that this definition is inaccurate. He stated that "...appealing to this right [bodily integrity] in the context of circumcision entails a misunderstanding of the nature of this right."  In short, Dr. Mazor pointed out that "bodily integrity" cannot mean you never do something to another person's body without their consent. There are times - such as critical surgeries or vaccinations - when you cannot get consent from an individual in order to do something beneficial for their health. He pointed out that the right to bodily integrity only applies to situations in which the procedure in question is unarguably not beneficial, neither medically nor otherwise (e.g., certain cosmetic procedures), and is being performed on the individual for others' benefit - not for the patient's own benefit.
Why are we including the ethics as well as the evidence in this article?
With pre-autonomous children, the authority to make medical decisions usually lies with the child’s parents, who have a duty of care toward the child. This duty involves seeking to promote the child’s long-term best interests...
Ironically she admits that autonomy includes allowing parents to make decisions for the child.
Another approach to respecting autonomy of an infant is to consider what the infant would choose for himself if he were competent.
This statement is even more ironic. The source I cited above stated that choosing circumcision at birth is not medically or morally equivalent to choosing circumcision at an older age. One simply cannot compare the two.
Nevertheless, a YouGov survey found that uncircumcised American men were three times more likely than circumcised men to regret their parents' decision.  So if we are to make the decision the baby is less likely to regret, we should circumcise. Obviously, I'm not on that train. I think we should make the medically best choice, especially in cases where the child regretting the parents' choice is unlikely (as in circumcision, where most guys are perfectly happy with their penises regardless of their status).
The principle of justice also refers to everyone having an equal opportunity for health; health care should not be based on sex, race, religion, etc.
Actually what justice means is health care should not be denied based on sex. As a family nurse practitioner, I won't offer a pap test or a mammogram to a man nor a prostate exam to a woman. Justice entails that I won't deny a patient medical services based on sex, not that I will offer them the same treatment. So justice doesn't apply to circumcision, which applies only to male patients.
The prepuce in human anatomy
Development of the sexual organs
She could have just said, "We will limit this article to male infants, not female or intersex infants." Instead, she unnecessarily confuses the issue with a lengthy discussion of intersex. This discussion suggests that she was biased against circumcision from the start - because only anti-circumcision activists pretend that male and female genitalia are similar or that the extremely rare issue of intersex is significant to the discussion. Neutral and pro-circumcision sources generally make no mention of intersex because they're obviously only discussing male circumcision, or they add a very brief statement along the lines of, "Circumcision should not be performed on intersex infants or when the sex is ambiguous." Call this the first obvious red flag that author Rebecca Dekker was anti-circumcision from the start.
Newborn males are normally born with their prepuce fused to their glans penis by a membrane. This tissue connection is normal at birth, making it so that the prepuce cannot be retracted, or pulled back from the glans.
Her statements about retractability are true. There's actually a wide range of retractability rates and we don't know what the true rate is or should be. For example, one study found 90% of foreskins at age 3 are retractable, while another found that only 37% were retractable at age 6. 
By 10 years of age, more than 50% of boys can completely retract their prepuce. 
She implies that it's normal not to be able to retract at puberty. But 76% of boys aged 9-11 who can't retract have an autoimmune disease called lichen sclerosus, which causes penile cancer. The study does not prove that all boys should be able to retract by puberty. However, it does call into question the hypothesis that failure to retract at that age is completely normal and should not be a concern. 
Functions of the prepuce
The prepuce is a normal part of the body’s genitals, common to males and females, human and non-human primates, and all mammals.
Actually, most mammals have a sheath into which the entire penis retracts. The human foreskin is unique in that it only covers the tip of the penis. The human penis is unique compared to other mammals generally and to non-human primates specifically. 
The prepuce is nerve-laden tissue that, in males, covers and protects the glans penis and the male urinary opening from irritation
The source that she cited  did not provide any evidence. The truth is that uncircumcised boys have more inflammation and infection of the glans and meatus, while meatal stenosis is not significantly different between circumcised and uncircumcised males. 
the circumcised penis goes through a process called keratinization, which changes the skin on the glans penis from shiny, smooth, and moist to dry and slightly more toughened, or callused.
She didn't cite any sources to support her claim. Call this another major red flag. The only study that compared the thickness of the glans skin of circumcised and uncircumcised penises found no difference. 
In an intact adult male, the average prepuce is around 37 square centimeters of skin
According to her source cited,  it's actually 35 square centimeters (5.4 square inches), which means the average is roughly 1.5 inches long.) In other words, she made a minor error, but basically told the truth; so that's actually really nice. Most intactivists claim that the average foreskin is 15 square inches (97 square centimeters).
Care of the intact penis
Everything she said about care of the uncircumcised penis is true. Here's another source that basically says the same thing but cites more than just two sources.  I wonder why she didn't discuss care of the circumcised penis.
Where did circumcision come from?
We know from Egyptian mummies and wall paintings that circumcision goes back at least as far as ancient Egypt.
That was 5,000 years ago. Actually, we have cave wall paintings in Spain and France dating to 20,000 years ago that depict circumcised penises, so we know it goes back at least 20,000 years ago. Circumcision has been practiced by ancient groups on every continent, suggesting that it originated before humanity spread across the planet. The Australian Aborigines, who are circumcised, arrived in Australia 35,000 years ago; and humanity is thought to have arisen out of Africa 70,000 years ago. So some researchers suggested that circumcision started 70,000-100,000 years ago. But again, the earliest proof we have is cave wall drawings from 20,000 years ago. 
There is very little evidence for any of the theories of the ancient origins of circumcision, but following is a partial list of those theories:
The pharaohs and upper classes were almost universally circumcised, and there's obviously a huge difference between circumcision and amputation of the entire penis. So why would Egyptian circumcision, which was a "godly" practice of the pharaohs, be a punishment for prisoners or slaves? That stretches credulity.
Her citations   typically refer to Jewish circumcision, which was not a blood sacrifice. The Jewish practice is based on the Book of Genesis, which states that circumcision is a sign of the covenant between God and Abraham. 
Those theories are all basically just conjecture anyway, so if anything, at least it shows that we don't really know why people started circumcising. Ancient Greek writings stated that ancient Egyptian circumcision was a hygiene decision. (But as I mentioned, circumcision goes back much further than that.)
Observant Jewish parents have carried out the ritual for more than 3,000 years in a ceremony called Brit milah... Most male circumcisions around the world are performed in Muslim communities (roughly two-thirds of all circumcisions) ... Some Christians also practice circumcision; however, the New Testament specifically states that non-Jewish Christians do not need to be circumcised
She avoids the false intactivist claim that Jewish circumcision was different in ancient times than it is today.  Her statements about Muslim circumcision are also true. I appreciate that she did not claim that Christians are forbidden from circumcising - another common falsehood.
Modern non-religious circumcision
we can trace the origins of routine, non-religious circumcision on healthy newborn males back to the U.S. in the 1870s.
She claims that circumcision's first modern medical advocates were people who believed an 1870s theory. The truth is it started in 1855 with Hutchinson's observation (since verified with modern research) that circumcised men were less susceptible to syphilis. Research from the late 1800s and early 1900s showed reduced syphilis and penile cancer in circumcised men and reduced cervical cancer in their wives.
She almost exclusively cites anti-circumcision activists, who themselves selectively cite the oddest claims.
There were also overtly racist proposals to forcibly circumcise Black males.
There was one proposal to forcibly circumcise and castrate black males after the Civil War. It was not taken seriously.
medical historians argue that one of the main reasons circumcision became routine in the nineteenth century was because of a major effort to stop masturbation.
Few sources that promoted circumcision mentioned masturbation, and few sources that demonized masturbation mentioned circumcision. No medical textbooks from the era promoted the theory that circumcision prevents masturbation. Evidence suggests that very few medical professionals actually believed the claim.  
The government-funded National Health Service (NHS) was established to provide affordable healthcare in times of scarcity. Every medical procedure was subjected to careful study so as not to waste precious resources. In 1949, Douglas Gairdner, a respected English pediatrician, published a paper critiquing the practice and confirming the wisdom of the 1948 NHS decision to stop covering the costs of routine circumcision.
The argument that every medical procedure was carefully studied to ensure a wise use of resources was not the case with circumcision and also not necessarily the case with everything other than circumcision. The NHS was created by politicians - specifically Aneurin Bevan, the Minister of Health, who had no medical background and was not educated past the age of 13. Others who helped create the NHS - such as the previous Health Minister, Henry Willink - also had no medical background. Medical services were to be provided based on need; since boys don't need to be circumcised, circumcision naturally would not have been included.
At any rate, it was not the case that circumcision was excluded in response to careful study as the first widely-promoted anti-circumcision article was published in 1949,  while the NHS was first created in 1948. And the NHS did not decide "to stop covering" newborn circumcision, as she claims, when it never covered circumcision to begin with. So it was not a decision to end coverage based on careful study of the science. It was quite literally the unilateral decision of a non-medical bureaucrat with no formal secondary education.
Basically, she cites every intactivist theory of the history of circumcision without bothering to even mention responses or theories by circumcision advocates. Again, so much for "evidence-based."
Why do parents choose non-religious circumcision today?
After expending a lot of energy earlier to argue that it's primarily a cultural or religious decision, here she cites several studies showing that the primary reasons were medical.
For example, the first Canadian study cites medical reasons as first (70% total: 51% hygiene, 15% prevention of infection or cancer, 4% doctor advises it) and only a minority were potentially cultural (21% total: 8% father is circumcised, 8% personal preference, 2% it just seems right, 1% to look like other boys, 2% other) or religious (6%). Oddly, she mentions that the primary driver of the circumcision decision was whether the father was circumcised, stating that 82% of circumcised fathers wanted to circumcise. But she doesn't mention that in the same study 85% of uncircumcised fathers did not want to circumcise - so it goes both ways. It's almost as if she's trying to imply that only circumcised fathers are biased by failing to mention the data that shows uncircumcised fathers may be equally biased.
perceived health benefits were closely tied to cultural beliefs supporting circumcision. This means that parents' beliefs about potential health benefits from circumcision are greatly influenced by their cultural beliefs about the practice.
She implies that this is only true for circumcised fathers, but the first study she cited proved that it is equally true for uncircumcised fathers. (She does later say, "or vice versa if newborn circumcision is perceived as socially abnormal.")
In a podcast episode on the topic published by Medical Ethics, a group of 3 parents discussed why they chose circumcision.
It's super odd that an "evidence-based" article  would cite podcasts and blogs! I don't recall her ever deviating from "evidence-based" on any of her other medical articles. Call this another red flag showing her bias. Since one can cherry-pick any podcasts or radio shows or blogs to support an opinion, I'll skip this section.
Worries about teasing or bullying
She suggests that teasing depends on where you live. I've read a couple case studies and news articles about an American boy who circumcised himself because of teasing, an African boy who circumcised himself because of teasing, and a British boy who was depressed because of teasing over his circumcised penis. I personally feel that we should make the decision based on what is medically best, not based on whether a boy may get teased. I wouldn't turn down a necessary or beneficial surgery because it might leave an unsightly scar, so I don't see why circumcision is different. 
How common is circumcision around the world?
Another statement that we hear from parents in the U.S. is that “I want my son to look like everyone else.”
Dekker implies that a mother's belief that circumcising her son will make him look like the majority of the American males is incorrect. However, her implication is itself incorrect. She discusses circumcision rates in other countries, but the rate of circumcision in Taiwan is irrelevant to someone who wants her son to align with an American norm. In other words, she used an intactivist talking point ("most men worldwide aren't circumcised") in an irrelevant way.
A more recent review by Morris et al. (2016) estimated the global prevalence of circumcision to be slightly higher, about 38%. However, this may be an overestimate as he assumes that the circumcision rate in China, the most populated country in the world, is 14% (a high estimate).
While Morris's estimates  are based on research, she fails to cite any references to demonstrate him wrong. If she wanted to disagree with him in an evidence-based way, she should have provided some evidence to contradict him.
In fact, his estimate may actually be an underestimate. For example, he states that the circumcision incidence in Canada is likely 50% because it was higher in prior decades than it is today. But the only research in Canada is on the newborn rate (30%), so he put it at 30%. He also assumed that the medically-necessary circumcision rate is only 0.1%, which is lower than the rate even in vehemently anti-circumcision Denmark. In countries where the circumcision incidence is not reported, he based it on the Jewish and Muslim rates plus an assumption of 0.1% medical necessity for uncircumcised males and an assumption that no non-Jewish and non-Muslim males are circumcised - which is obviously false. Since the circumcision rate is rising around the world - especially in Africa, China, and India for preventative reasons - that also means his estimate is an underestimate.
In the U.S., an estimated 71% of adult men are circumcised
According to CDC data, it's 80.5%.  She doesn't cite her source for the 71% figure. (Again, so much for "evidence-based"). I do find it interesting that she mentions the low of 31.4% in 2003 in Western states without mentioning that in 2010, the rate in Western states had risen by almost ten percentage points to 40.2%. She also didn't mention the 2010 high of 71.0% in Midwestern states, nor the all-time high of 82.9% in Midwestern states in 1998. The only precise figure she provided was the all-time low of 31% (rounded down from 31.4%). It seems odd that she would give the all-time low in a given region without also giving the all-time high, nor the current rate in the same region. 
She states that Medicaid discontinued coverage in 18 states as of 2015.  However she doesn't bother to cite Medicaid information more recent than 2015. In response to evidence about circumcision benefits' cost-effectiveness, several states reinstated Medicaid coverage following the release of the 2012 AAP position statement.  As of 2019, Medicaid covers circumcision in 38 states and does not cover it in 12 states.   Other states are also considering reinstating coverage.
The circumcision procedure
While stating that the Mogen clamp was involved in two lawsuits over amputations, she fails to mention that it was redesigned to prevent amputations. For example, it can no longer be opened very wide, so the glans won't fit into the clamp anymore.
When healthy adult males elect circumcision, there is no need to break tissue adhesions, which means that this particular step — which can be painful for the baby even with anesthesia applied (Brady-Fryer et al. 2004) — is not needed.
While this is true, she seems to imply that adult circumcision is better. Research shows that adult circumcision is associated with a roughly 10-fold higher complication rate. Furthermore, it's less likely to be covered by insurance and costs roughly 10 times more than newborn circumcision. (If an adult wants circumcision, he's less able to afford it, unlike circumcision reversal, which can be nonsurgical and free.) Adult circumcision requires that the patient avoid sexual activities that would produce an erection, and take time off from work or school. The recovery period may interfere with his mobility. None of these issues apply to a newborn. Also, the adult patient will remember the pain and the experience, whereas a newborn will not.
Interestingly, a 2014 study found that penile amputation was more common with circumcisions performed after the age of 1 than before. In fact, amputation was more common in the group of boys who had not been circumcised in infancy, even though that group includes boys who were never circumcised. However, the difference was not statistically significant, meaning it was so rare that they couldn't determine whether the higher incidence of penile amputation in uncircumcised infants was real or due to chance. (It was 3.9 per million uncircumcised vs. 2.3 per million circumcised, a non-significant 41% reduced incidence in circumcised infants). Also, the amputations were total for uncircumcised boys vs. partial for circumcised boys.  The fact that amputation is not statistically different between circumcised and uncircumcised boys renders her entire discussion of the two Mogen amputations irrelevant.
After 24 hours, the lubricant is applied directly to the baby’s wound (without gauze) with each diaper change for the next three weeks,
I find it kind of funny that she repeatedly refers to a wound instead of penis (e.g., "the provider covers the baby's wound in a dressing"), even though it's more accurate to say (s)he covers the penis in a dressing, since the dressing covers the entire penis - head, cut line, and shaft - not just the cut line. I've never seen it phrased as a wound in a textbook or unbiased article describing the procedure. It seems as if she's intentionally straying from accurate medical language in order to use emotionally-laden language. She's not wrong, but it's just interesting language.
and within a few days a scab will form (Baskin, 2019)
Healing tissue that is yellow in appearance does appear on the glans a day or two after the circumcision and lasts several days, but an actual scab doesn't form. Perhaps she's referring to the yellow healing tissue, but that's actually accurately described as granulation tissue, not a scab. It seems as if she's deliberately using emotive (and inaccurate) language.
What is the evidence on circumcision to prevent infection or disease?
Cultural bias in the medical research
Despite growing ethical concerns in recent years, researchers have carried out many studies examining the medical effects of male circumcision.
She seems to imply that it is unethical to study a beneficial medical procedure. That seems like an extremely odd position to take - especially when we consider that circumcision in the modern era started with observations of the differences between religiously circumcised and uncircumcised males. So it's not as if some doctors living in a scientific vacuum theorized that this would be a great thing to do, started performing it without good reason, and then began to study it after the fact. That is what happened with terrible procedures like clitoridectomies on girls and women (FGM), lobotomies on psychiatric patients, and others.
The progression of circumcision in modern Western culture is actually quite logical. Researchers noticed differences between men who were already circumcised (or their wives) and men who were not circumcised. Armies discovered that uncircumcised soldiers were more often sick, less productive, and more costly. Consequently, based on these observations circumcision rates went up. Simultaneously, researchers from around the world, including those opposed to the practice, conducted research to verify that their observations remained the same - in order to advise against the practice if it turned out they were wrong. Her comment and the way she phrased it indicate bias.
As we conducted our literature review, it became clear that most researchers based in the United States, where the majority of medical research is done, took the cultural and ethical acceptability of male circumcision for granted.
She implies that the United States is the only country with a possible bias. The irony is that if only half of boys in the U.S. are circumcised - as she falsely implied earlier in the article - that would make the U.S. one of the least biased countries on the planet. She can't have her cake and eat it, too.
Accordingly, the explicit goal of most studies was to ‘verify’ the perceived benefits of the surgery.
The goal of the first studies was to explore relationships (and in some cases, they came to the opposite conclusion from what they expected - i.e., they expected to discover circumcision harm but instead discovered benefit). Later studies further tested the links observed in the earliest studies. This is how science works. In some cases, where the research is undeniable (e.g., 100% of studies and 100% of meta-analyses on UTI show that circumcision reduces UTI risk), future research aimed primarily to determine the degree of benefit - but that was certainly not the case for the earlier studies.
For example, Dr. Thomas Wiswell was vehemently anti-circumcision and actually conducted research trying to reduce medically-necessary circumcision rates. Conducting a study hoping to disprove the hypothesis that circumcision reduces UTI risk; he instead confirmed the hypothesis. In fact, he not only assessed UTI risk but also circumcision complications. He expected that any reduction in UTIs would not outweigh the risks of the procedure. Instead, he found that in the first month of life, there were zero deaths in more than 100,000 circumcised boys but two deaths in fewer than 36,000 uncircumcised boys. Both deaths were caused by urinary tract infections. He found that uncircumcised boys were more likely to suffer a UTI than circumcised boys were to suffer either a UTI or a circumcision complication. 
Also of note is that the rabidly anti-circumcision movements started in America - precisely the place you would expect to be biased in favor of circumcision. So there's a significant risk of anti-circumcision bias in American research. (In fact, we do see such bias in some American research.)
In short, her argument that Western research is biased in favor of circumcision is wrong. In her comment that a largely circumcised group of researchers are more likely to be biased in favor of circumcision, she again gives the false impression that only circumcised males are biased - without stating that the reverse is also true. In other words, uncircumcised male researchers and researchers from non-circumcising cultures are likely to have an anti-circumcision bias.
On a separate note, it's interesting that she states that the United States produces most of the world's research. This is true, but I think most readers will miss the significance of what she's saying. The U.S. produces one third of the world's research on all topics combined. So it should not be surprising that the U.S. produces the most circumcision-related research. The plethora of circumcision research is not based on bias; it's based on the availability of research dollars. 
Limitations of the research
One of the main problems with the research on the proposed benefits of the routine male circumcision of healthy newborns is that much of the research comes from contexts in which circumcision was performed on males during adulthood.
Her observation is ironic, since earlier she implied that adult circumcision is preferable because of a lack of adhesions - without considering the rates of other complications or any other issues. Yet here she implicitly admits that adult and newborn circumcision are not necessarily comparable.
For example, there have been several randomized controlled trials (RCTs) on HIV infection after adult male circumcision in Africa, but those men were also provided with individualized counseling on safe sex practices and free access to condoms—which wouldn’t be possible with newborn circumcision in Africa or elsewhere.
The example she gives is particularly ironic. She implies that it's better to circumcise adults than newborns when considering the STD reduction effect. She neglects to mention that those three RCTs also found the use of condoms was not affected by the counseling or provision of free condoms, and that - in spite of the researchers' efforts - condom use remained very low for both circumcised men and uncircumcised men.
Plenty of research has shown that teaching people about the importance