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Tainted evidence

A critical analysis of Rebecca Dekker's "evidence based" circumcision article

October 26, 2019


Rebecca Dekker PhD RN, a nursing professor and founder of the Evidence Based Birth website, posted an article, "Evidence and Ethics on: Circumcision." [1] 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." [2]

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

Introduction

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. [3] 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. [4] 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, [5] 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 [6] and the CDC in 2018. [7] We can anticipate a rise also because some states have reinstated Medicaid newborn circumcision coverage. [8] (Rates are 24 percentage points higher in states where Medicaid covers the procedure.) [9] 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. [10]

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." [11] 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. [12] 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. [13]

By 10 years of age, more than 50% of boys can completely retract their prepuce. [14]

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. [15]

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. [16]

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 [17] 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. [18]

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. [19]

In an intact adult male, the average prepuce is around 37 square centimeters of skin

According to her source cited, [20] 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. [21] I wonder why she didn't discuss care of the circumcised penis.

Where did circumcision come from?

Ancient origins

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.[16] [22]

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:

  • To punish prisoners of war

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.

.

  • A blood sacrifice

Her citations [23] [24] 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. [25] 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. [26] 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.