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Red Herring Research

December 19, 2020 The website Saving Our Sons posted a quiz created by intactivist James Ketter - purportedly as a way to determine whether parents who choose circumcision actually did their research. Ketter concluded by declaring that any parent who cannot pass his pop quiz "did NOT research, or make an educated decision to circumcise" her son. [1]

This quiz is nothing more than a red herring, designed as a tool for intactivists to portray a decision in favor of circumcision as one of ignorance. [2] Most of Ketter's questions ask for details that are completely unnecessary for a parent to research in order to make an informed decision. His answers - which include absurd choices (e.g. "traditional tribal method") and histrionic terms (e.g. "destroyed" in lieu of "removed") - aren't based on science or medicine, but are simply regurgitations from other intactivist sources.

Let's examine these questions.

1a) In what style did you choose to circumcise your son? (a) Low and Loose, (b) Low and Tight, (c) High and Loose, (d) High and Tight, (e) Radically High, (f) Radically tight, (g) Dorsal Slit, (h) Button Hole

1b) What are the benefits and negatives of each style?

Parents don't need to research a particular circumcision "style". It would be rare for a doctor even to ask this question to parents of newborns.

2a) What method of circumcision did you request for your child: (a) Plastibell, (b) Mogen Clamp, (c) Gomco Clamp, (d) Freehand, (e) Traditional Mohel, (f) Traditional Tribal, (g) Electro-cauterization 2b) What are the risks and possible complications associated with each method?

A circumcision specialist or medical clinic typically performs the procedure using one type of method. There is no menu of options. The appropriate question that a parent would ask is, "What circumcision method do you use?" The three most common methods of newborn circumcision (Gomco, Plastibell, and Mogen) are very similar in outcomes. Although the Mogen has a lower complication rate, less pain, and a better cosmetic outcome, the differences are insignificant. [3]

To our knowledge none of the other methods is widely available in North America. It appears that Ketter erroneously equated "traditional Mohel" with "metzitzah" - a Jewish ritual that involves drawing blood from the wound. Ketter appears ignorant that some mohelim use a tube to avoid direct oral contact and protect against transfer of herpes and other infections. The unhygienic practice of direct oral contact is not a circumcision method; it is a ritual performed by a small number of ultra-Orthodox mohelim.

Electro-cauterization is so rare that our resident pediatrician had not heard of it being used for surgery on an infant. A Circumcision Choice article on the tragic case of David Reimer discusses this method. [4]

By citing frenulum removal as a complication, Ketter demonstrated his misunderstanding of the term. "In medical terms a complication is a unexpected or unplanned bad result." Because circumcision may include removal of the frenulum, the loss of the frenulum is not unexpected or unplanned, so the loss of the frenulum is not a complication. [5] While Ketter referred to the frenulum as "the male G-spot," pro circumcision researchers have pointed out that there is little scientific evidence for the assertion that the frenulum is highly erogenous. [6]

The most important factor is not the method used but rather the practitioner's level of experience. A procedure by a doctor who has performed 1,000 circumcisions using the Plastibell will likely be better than one by a doctor who has performed 100 circumcisions using the Mogen clamp. That said, the outcomes are also extremely similar between doctors who have performed 20 to 100 circumcisions and those who have performed more than 100 circumcisions. A doctor who has finished his internship and residency has done far more than 20 circumcisions and is mostly likely sufficiently competent. Therefore the information that a parent would want to know is how much experience the person performing the procedure has.

3) What are the most common possible immediate complications of the circumcision surgery?

Ketter failed to include a crucial statistic that a parent would need in order to make an informed decision: the likelihood of complications. The most common complications "are rare, occurring in approximately 1 in 500 newborn male circumcisions. Acute complications are usually minor and most commonly involve bleeding, infection, or an imperfect amount of tissue removed." [3]

The author claimed that common complications include pain, inability to bond with mother, difficulties with breastfeeding, and post-traumatic stress disorder (PTSD). While pain is a complication with any surgery, patients today receive anesthesia to help them manage discomfort. The AAP recommends that all patients receive adequate pain relief during and after the procedure. Ketter provided no evidence for the other complications he alleged. Several studies show that circumcision is unlikely to have any significant effect on breastfeeding. [7-12] The PTSD claim was examined for our article examining the psychological effects of circumcision. Taken as a whole, the studies typically cited do not show that neonatal circumcision patients suffer significant psychological harms - neither immediate nor longterm. [13]

4) What is the most common possible LATE term complication of circumcision? (from procedure to 12 years)

Ketter claimed that the rate of meatal stenosis varies from 5%-30% for circumcised boys - a rate significantly higher than that reported in medical studies. A meta-analysis conducted by pro-circumcision researchers of several studies found that the risk of meatal stenosis in circumcised males is less than 1% and that the risk was not significantly higher than that for uncircumcised males. [14] A 2015 study found that only half of symptomatic cases will require treatment. Furthermore, severe complications of meatal stenosis are extremely rare. [15]

The idea that meatal stenosis is more common in circumcised boys is based on studies like one by Robert Van Howe, a physician with an extensive background promoting an anti-circumcision agenda. Van Howe’s study lacked a sufficient number of uncircumcised boys to obtain a statistically significant result. [16] On the other hand, one study found that applying petroleum jelly to the penis following circumcision reduced the meatal stenosis incidence from 6% to 0%, [17] which seems to suggest that circumcision may indeed play a role.

In any case meatal stenosis is a simple problem to fix. "In some cases a steroid cream may be applied to the meatus. In most cases, a surgery called meatotomy is the best treatment. It involves cutting apart the stuck part of the meatus so that the opening is made bigger. Following this surgery it is rare for meatal stenosis to return." [18]

5) What is the greatest risk factor for ADULT men circumcised in infancy?

Ketter wrote that circumcised men are 4.5 times more likely than uncircumcised men to experience erectile dysfunction. For this statistic he relied on a 2011 study by longtime anti-circumcision activist Dan Bollinger and the aforementioned Robert Van Howe. [19] Since the recruitment method allowed for self-selection bias, the group of respondents may differ from the general public. [20] And the study was based on self-reporting, which is a less reliable method for obtaining data than researcher examination. Moreover, Ketter failed to follow Bollinger and Van Howe's caution for readers not to extrapolate the study results to the general population. [19]

6) What is the most common cause of foreskin infection in [uncircumcised] boys?

The author provided no statistical data or other evidence for his assertion that the most common cause of infection for uncircumcised boys is forcible retraction. Given that Denmark is the most foreskin-friendly country on earth, it stands to reason that Danish parents and caregivers know how to care for the foreskin. Therefore a study that was conducted in the capital region of Denmark - which found that 5% of boys under 18 suffered a foreskin complication significant enough to require treatment at a medical center - suggests that the cause is something other than forced retraction. [21]

Studies show that circumcision reduces the risk of a urinary tract infection in the first year by 80-90%. [22-24] A UTI can lead to sepsis, which causes inflammation, blood flow problems, low blood pressure, trouble breathing and vital organ failure. Newborns and infants under three months are especially at risk for sepsis. [25] While antibiotics can be used to treat a UTI, both the World Health Organization and U.S. Centers for Disease Control have advised that antibiotics should be used sparingly. The WHO is concerned that UTIs have become more resistant to antibiotics, [26] [27] which the CDC warns can have harmful side effects. [28] By significantly reducing the incidence of UTIs, newborn circumcision reduces the need for use of antibiotics in the first place.

7) How do you clean and care for a circumcised boy's penis immediately after circumcision? List all necessary steps.

8) How do you clean and care for a circumcised boy's penis after healing? List all necessary steps.

It is irresponsible for James Ketter - a department store salesman with no medical background or training - to furnish medical advice. Should parents follow his advice and something goes wrong, he has opened himself up to potential liability. And the very notion that parents must research after-surgery care is silly, as this information is routinely provided by the medical or religious practitioner. We've included in the footnotes a few medical sources that provide sound, sober, post-operative care instructions. [29-31] We caution parents: follow the instructions provided by the circumcision specialist who performs the procedure for your son. If any complications arise, contact your medical provider immediately.

9) How do you clean and care for [an uncircumcised boy's] penis? List all necessary steps.

We reiterate our caution about relying on medical advice from someone who has no medical credentials. Parents should follow the instructions provided by your son's medical provider. We've included links to medical sources with instructions for cleaning and caring an uncircumcised boy's penis. [30] [32-33]

10a) How does an adult [circumcised man] care for his own penis?

10b) How does an adult [uncircumcised man] care for his own penis?

We included in the footnotes an article that discusses penile care for circumcised and uncircumcised men. [34] Readers will also find an NHS (UK health services) article with specific instructions for cleaning an adult uncircumcised penis. The author interviewed a physician who specializes in sexual health. He observed, "It's really surprising how many men don't clean underneath their foreskin. Not only do they regularly develop complications from poor hygiene, but it's also very off-putting for a sexual partner." [35] Of course circumcised men don't have to worry about smegma, and rarely does a circumcised penis exhibit the strong unpleasant odor that is common to some uncircumcised organs.

Ketter failed to include the NHS instruction to use warm water, the dangers of washing too frequently or not frequently enough, and the need to avoid using deodorants. The NHS advised that one may use "a mild or non-perfumed soap to reduce the risk of skin irritation", an option that differs from Ketter's warning to avoid soap at all costs. " Ketter also added reference to a "natural cleaning mechanism" that is absent from medical literature.

*Bonus Question*: What are the 16 functions of the foreskin lost to circumcision?

The 16 foreskin functions are a joke. We examined and refuted each of these so-called functions back in 2017. The correct answer is: circumcision does not eliminate any bona-fide physical or sexual functions. [36] Science-based studies show that circumcision does not adversely affect the three functions of the penis.

[1] James Ketter; "I Researched Circumcision! ...Did You Really?"; Saving our Sons; October 2014

[2] TBS Staff; "15 Logical Fallacies You Should Know Before Getting Into a Debate"; The Best Schools; June 9, 2020. "A 'red herring fallacy' is a distraction from the argument typically with some sentiment that seems to be relevant but isn’t really on-topic. This tactic is common when someone doesn’t like the current topic and wants to detour into something else instead, something easier or safer to address. A red herring fallacy is typically related to the issue in question but isn’t quite relevant enough to be helpful. Instead of clarifying and focusing, it confuses and distracts."

[3] Susan Blank M.D. et al: AAP Technical Report; Pediatrics; September 2012. "In general, the specific technique used does not afford a significant difference in risk of complications."

[4] "David Reimer - the rest of the story"; Circumcision Choice; June 2, 2018

[5] "Intactivist Lie of the Week: All or Most Circumcisions Result in Complications"; Circumcision Facts and Science; July 10, 2017

[6] Stefan A. Bailis et al; "Critical Evaluation of a Survey Claiming "Long-Term Adverse Outcomes from Neonatal Circumcision"; Advances in Sexual Medicine; September 26, 2019. "Given that the underside of the glans, where the frenulum attaches, is a highly erogenous area, even in males without a frenulum, it begs the question, is the frenulum the real source of erogenous sensation in men who claim their frenulum is erogenous? After all, since the frenulum attaches at the erogenous point, stimulation of the frenulum will, inevitably, stimulate the highly erogenous underside of the glans."

[7] Howard, C. R., Howard, F. M., & Weitzman, M. L. (1994). Acetaminophen analgesia in neonatal circumcision: The effect on pain. Pediatrics, 93:641–646.

[8] Marshall, R. E. et al; "Circumcision: Effects on mother-infant interaction"; Early Human Development; 1982

[9] Dixon, S., Snyder, J., Holve, R., & Bromberger, P.; Behavioral effects of circumcision with and without anesthesia; Journal of Developmental and Behavioral Pediatrics; 1984

[10] Fergusson, D. M. et al; Neonatal circumcision: Effects on breastfeeding and outcomes associated with breastfeeding.

[11] Mondzelewski, L., Gahagan, S., Johnson, C., Madanat, H., & Rhee, K.; Timing of circumcision and breastfeeding initiation among newborn boys. Pediatrics; 2016

[12] Gattari, T. B. et al; "Neonatal circumcision: Is feeding behavior altered?" Hospital Pediatrics; 2013

[13] Andrew Gross; "Does circumcision cause psychological damage?"; Circumcision Choice; DATE.

[15] Shelley P. Godley et al; "Meatal stenosis: a retrospective analysis of over 4000 patients"; Journal of Pediatric Urology; February 2015

[16] Robert S. Van Howe MD; "Incidence of Meatal Stenosis following Neonatal Circumcision in a Primary Care Setting"; Clinical Pediatrics; January-February 2006

[18] "Meatal Stenosis: Management and Treatment"; Cleveland Clinic; last reviewed August 9, 2016

[19] Dan Bollinger, Robert S. Van Howe; "Alexithymia and Circumcision Trauma: A Preliminary Investigation"; International Journal of Men's Health; 2011

[20] "Selection bias"; Institute for Work and Health; May 2014. "Selection bias also occurs when people volunteer for a study. Those who choose to join (i.e. who self-select into the study) may share a characteristic that makes them different from non-participants from the get-go."

[21] Ida Sneppen and Jørgen Thorup; "Foreskin Morbidity in Uncircumcised Males"; Pediatrics; May 2016

[22] EJ Schoen et al; "Newborn circumcision decreases incidence and costs of urinary tract infections during the first year of life"; Pediatrics; April 2000. "Newborn circumcision results in a 9. 1-fold decrease in incidence of UTI during the first year of life."

[23] D Singh-Grewal et al; "Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies"; Acute paediatrics; May 12, 2005. "The odds of UTI in circumcised boys are about 0.1 when compared with uncircumcised boys. This represents a reduction in odds of nearly 90%."

[24] Michael L. Eisenberg et al; "The Relationship between Neonatal Circumcision, Urinary Tract Infection, and Health"; The World Journal of Men's Health; March 2018. "Importantly, no difference in the rate of UTI was identified in the first two weeks of life. However, up to 2 years of age, uncircumcised boys had a higher rate of UTIs compared to circumcised boys (2.68 per 100 person-years vs. 0.59 per 100 person-years)."

[25] "Sepsis in children: Know the signs"; Children's Health

[26] Debora MacKenzie; "UTIs could soon be life-threatening without new antibiotics"; New Scientist: February 20, 2017

[27] Matt Richtel; "Urinary Tract Infections Affect Millions. The Cures Are Faltering"; New York Times; July 13, 2019

[28] "Antibiotics Aren't Always the Answer"; Centers for Disease Control; August 23, 2018

[29] "How to Care for Your Baby's Penis: The Circumcised Penis"; Healthy Children; last updated November 23, 2016

[30] Maria Masters; "Newborn Circumcision Care"; What to Expect; reviewed December 19, 2018

[31] Nicole Pietrantonio, NP; "How to care for your child after the circumcision"; MassGeneral for Chidren YouTube video; November 12, 2019

[32] "Care for an Uncircumcised Penis"; Healthy Children; last updated June 19, 2017

[33] "Penis and foreskin care"; The Royal Children's Hospital Melbourne; reviewed February 2018

[34] Sian Ferguson; "Everything You Need to Know About Penis Health"; Healthline; March 26, 2019

[35] "How to keep a penis clean"; National Health Service (United Kingdom); last reviewed April 6, 2018

[36] "The 16 Foreskin Functions - a critical analysis"; Circumcision Choice; November 2017


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