10 10 240 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>Circumcision promoters given open slather</h3> An extraordinary feature of the United States today is the widening gulf between popular and professional medical attitudes towards routine circumcision, and the sharp divisions of opinion among medical and health professionals themselves. On one side we can see a flood of attacks on circumcision on <a href="http://www.circumstitions.com/blogs.html">blogs, websites, Youtube and in the mass media</a>; more and more young parents deciding not to circumcise their boys; increasing numbers of circumcised men voicing their anger and resentment at having been circumcised, and taking up the onerous task of foreskin restoration; and if that was not a sufficient indication of the way the wind is blowing, it appears that a significant number of Jewish Americans are also abandoning circumcision in favour of <a href="http://www.jweekly.com/article/full/63891/alternative-ritual-sans-snip-catching-on-in-bay-area/comment/">peaceful naming ceremonies</a>. Given the <a href="http://nextmagazine.com/feature-article/tipping-point">swelling flood of critical comment</a>, it looks as though the "tipping point" <a href="http://www.cirp.org/library/legal/miller1/">predicted by Geoffrey Miller</a> is rapidly approaching. Within professional circles there is obviously no consensus on the issue and probably bitter argument behind closed doors. Both the Centers for Disease Control and the American Academy of Pediatrics have been “working on” new circumcision policy statements for years; every few months they announce that it is just about ready to be released, yet nothing emerges. It would appear either that they cannot find the evidence they need to justify a recommendation of infant circumcision in the United States, or that the members of the various task forces cannot reach agreement on the content or wording of the policy. In the meantime, medical authorities in both Australia and the Netherlands have issued policies that firmly reject routine circumcision, making it far more difficult for those who want to restore the old days. The problem for the CDC is that all the evidence for circumcision having a protective effect against HIV and human papilloma virus comes from experiments on adult men in African countries with extremely high levels of heterosexual HIV infection. These conditions simply do not apply in the USA (or any other developed country); since there are no American studies showing that circumcision has any protective effect against these problems, it becomes very difficult to “recommend” it as a routine health precaution. Quite apart from the bioethical and human rights issues, the so called “medical benefits” are simply not there. These developments clearly have some sectors of the American medical industry deeply worried, including, the editors of many US medical journals, who seem to think that the African AIDS crisis presents a heaven-sent opportunity to stop the rot. Over the past few years we have seen any number of scaremongering articles, with titles such as “Declining rate of circumcision despite increasing evidence of health benefits”, and numerous opinion pieces by diehard believers in circumcision, who paint lurid scenarios of the public health catastrophe that is sure to unfold if American parents stop circumcising their baby boys. (Indeed, according to one <a href="http://www.circumstitions.com/news/news44.html#colorado-senator">imaginative American senator</a>, the omission could even lead to epidemics of spina bifida and "neurogenic bladder" - whatever that is.) A recent effusion along these lines was produced by Aaron Tobian and Ronald Gray, both seasoned pro-circumcision warhorses with a long record of such advocacy. [1] Taking time off from their well-funded day job (circumcising ill-informed but trusting Africans), they penned a short opinion piece, published in the Journal of the American Medical Association, in which they asserted that what was good for Swaziland and Zimbabwe was also good for the United States. Now you might well feel that America’s desperate debt situation, unemployment crisis and general social dislocation means that it does have much in common with the less developed parts of darkest Africa, in which case it would perhaps follow that a tribal rite such as circumcision is entirely appropriate. Indeed, by asserting that parental power to circumcise children should not be in any way limited because this would be an affront to religious freedom, Tobian and Gray suggest as much. But their principal argument is to do with that other American dream – health. Because three clinical trials in South Africa, Kenya and Uganda appeared to show that circumcision of sexually active adult men could lower their risk of acquiring HIV in an environment of high heterosexual prevalence, baby boys in America should be circumcised as a precaution. We have heard this tired old argument so often from circumcision advocates that we must wonder why the editor of JAMA bothered to publish such a poorly-argued rehash of the same old stuff. But not only did he publish it, he also censored or refused to print letters criticizing the obvious flaws in this prescription. To our knowledge, at least 8 letters were submitted to the journal, only 2 of which were published, and one of these was so severely cut that the author complained that he had been censored rather than edited. Not content with suppressing contrary opinion, JAMA also published 2 letters in support of the Tobian and Gray’s position and, on top of that, gave them generous space for a “response” that allowed them to repeat their case all over again. What else could the editor do: if there are no good arguments or relevant evidence for a course of action he wishes to follow, the only thing to do is to keep asserting its necessity in the hope that if it is done often enough, people will come to believe it by sheer dint of repetition. In an attempt to overcome this blatant censorship, and to restore some semblance of decency and fairness to the medico-scientific debate about circumcision (a debate in which the negative is gagged most of the time), we publish a selection of the letters that JAMA refused to publish. We are not publishing Tobian and Gray’s original article because it was made freely available at the time, and heralded with a media release that was picked up all over the world, thus giving it massive exposure. You can easily get hold of it if you want it through the JAMA website. The letters published here focus on different objections to the circumcision solution, and one theme is indignation and wonderment that one of the world’s leading medical journals should publish such a poorly-argued case, particularly one that ignores the cardinal principle of evidence-based medicine: that treatments should follow directly from the evidence. Tobian and Gray need to go back to school and relearn their geography; contrary to what they seem to think, the United States is not Africa. We invite readers to compare the Tobian and Gray’s proposals with the arguments of their critics and make their own assessment of the who has the better case. [1] Tobian AAR, Gray RH. The medical benefits of male circumcision. JAMA 2011; 306: 1479-80. <h2>The letters JAMA refused to publish</h2> <h3>Ignores ethical and human rights issues</h3> Tobian and Gray ignore the substantial ethical and human rights implications of male circumcision as an HIV preventive. While they acknowledge that the best interests of the child are a primary consideration, they claim that banning neonatal male circumcision denies religious freedoms to Jewish and Muslim parents, which would be potentially unconstitutional. The opposite is true. Permitting parents to irreversibly mark their religion on the bodies of their children by amputating functional tissue is contrary to the law. After all, upon reaching adulthood, the child might choose to follow a different religion. In 1891, the United States Supreme Court recognized the right of all citizens to bodily integrity and self-determination. No right is held more sacred or is more carefully guarded by common law than the right of every individual to the possession and control of his own person free from all restraints or interference of others. [1] Joel Feinberg argues for the child’s right to an open future, [2] and the British Medical Association recommends prioritizing options that maximize the patient’s future opportunities and choices. [3] When children are incapable of consenting, parents possess temporary authority to make health care decisions on their behalf if the procedure is in the child's best interests. Parents do not possess unrestricted authority to make decisions on behalf of their children. Moreover, parents are not permitted to make martyrs of their children. [4] According to the American Academy of Pediatrics, parental permission for medical intervention is authorized only in situations of clear and immediate medical necessity, such as disease, trauma, or deformity. [5] Because parents lack the power to give permission for prophylactic amputation from their children of healthy tissue, and because neonatal circumcision has no universally recognized medical benefit, parental permission for the procedure is not effective. Where parents request a procedure that is not medically indicated, courts have required strong evidence that the procedure is in the patient-child's interests and does not entail parents injecting their own preferences into the decision-making process. The benefits of the proposed procedure must clearly outweigh short- and long-term disadvantages, and spiritual considerations may not be incorporated into this analysis. For non-essential treatments—such as neonatal circumcision--that can be deferred without loss of efficacy, the physician and family must wait until the child is old enough to consent. Judging by the low adult circumcision rates, most will hang onto what they have. References 1. Feigenbaum MS. Minors, medical treatment, and interspousal disagreement: Should Solomon split the child? De Paul L Rev 1992; 41:841-884. 2. Feinberg J. 2007. The Child’s Right to an Open Future. In Curren R, ed. Philosophy of Education: An Anthology. Malden, Massachusetts: Wiley-Blackwell: 112-123. 3. Medical Ethics Committee, British Medical Association. 2006. The Law & Ethics of Male Circumcision. London: British Medical Association. 4. Prince v. Massachusetts, 321 U.S. 158 (1944). 5. American Academy of Pediatrics Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995; 95: 314-317. J. Steven Svoboda, JD Hons (Harvard), MS (Berkeley) Executive Director, <a href="http://www.arclaw.org/">Attorneys for the Rights of the Child</a> <h3>Better methods of HIV control available</h3> Looking past the statistical sleights-of-hand that characterize the African RCTs upon which Gray and Tobian rely so heavily (and forgiving the Tuskegee redux situation which sent HIV infected African men back home untreated), both bioethical and practical issues intrude on their scheme. The fundamental bioethics of surgery generally – and epidemiology in particular – require that the least intrusive methods of disease control be systematically applied before more drastic measures are adopted. Gray and Tobian fail to mention that ART therapy reduces to near zero the likelihood of sero-conversion between discordant partners. Nor do they mention that barrier methods are themselves much more effective (and affordable) than male circumcision (MC). Neither has been widely available to Africans even while the funding for a massive campaign for MC appears available. Nor do Gray and Tobian discuss the morbidity and mortality (or iatrogenic transmission of HIV itself) such a campaign, whether in Africa or the USA, would entail. Gray and Tobian concede that the African RCTs may not be directly applicable to the situation in the USA, and admit there is a racial and social-class correlation accounting for the incidence of STIs. But in the USA, at least, this experiment has already been conducted, longitudinally no less, and failed miserably. The United States has the highest rate of HIV among Western countries, and also the highest rate of MC, around 70%. Circumcising American infants in 2011 is not going to shift those numbers significantly, even in the long term. Moreover, Gray and Tobian appear to be recommending a situation in which over-confidence in the prophylactic properties of MC will produce males who “risk compensate” by unprotected sex, thus over-balancing any claimed prophylaxis. We have already seen evidence of this in Sub-Saharan Africa. Mathematical models do not reflect that risk, which should be of great concern to vulnerable female partners, whether in Africa or the US. American children – circumcised in 2011 as a putative preventative of a disease of which they are not at risk until they become sexually active, and very careless – will have every right to demand in 2031 why less intrusive measures of disease control were not exhausted before they were ensnared in the Gray–Tobian scheme. They might point to Western Europe or New Zealand, where HIV rates are much lower than the USA, and circumcision is rare or non-existent Finally, we have been here before. A similar massive MC campaign, featuring similar tortured reasoning, was proposed to control the American black population in 1914. [1] Mercifully, the proposal failed. George C. Denniston, MD, MPH, President John V. Geisheker, JD, LLM, Executive Director, <a href="http://www.doctorsopposingcircumcision.org/">Doctors Opposing Circumcision</a>, Seattle 1. Hazen HH. Syphilis in the American Negro. JAMA 1914; 63(6): 463-8. <h3>Violates child’s right to physical integrity and Christian religious teaching</h3> Tobian and Gray suggested that Medicaid should pay for non-therapeutic circumcisions, including religious circumcisions of Jews and Muslims. By law, Medicaid tax dollars are to be used for medically necessary (not religious) services, and not wasted fraudulently on unnecessary surgeries. All fifty states should instead defund all unnecessary circumcisions. No national medical association in the world recommends routine circumcision, despite the opinions and questionable research of pro-circumcision advocates. Amputating (and selling) healthy body parts from children may be financially profitable for some, but it is unethical and violates Christian teaching. Father Edwin F. Healy, S.J. wrote, “Some physicians, it seems, circumcise all male infants, and their motive appears to be mercenary. Such physicians act in a manner unworthy of their high calling. ” [1] Tobian’s and Gray’s commentary was just the latest high-pressure sales pitch. Catholics (and other Christians) should not be forced to pay for non-therapeutic circumcisions. Catholic Catechism teaching (# 2297) states, “Except when performed for strictly therapeutic medical reasons, directly intended amputations, mutilations, and sterilizations are against the moral law.” [2] In 1999, the American Academy of Pediatrics described circumcision as “amputation of the foreskin." In 2000, the American Medical Association described elective circumcisions as “non-therapeutic.” [3] Fr Peter A. Clark, SJ, PhD summarized the problem with circumcision. “God created us in God's image and likeness” (Gen 1:27-28). It follows then that God created males with normal, healthy foreskins for the purpose of protecting the glans, providing natural lubrication to prevent dryness, and contributing significantly to the sexual response of the intact male. To surgically remove the foreskin for hygienic reasons, and/or to obtain other questionable benefits that absorb medical resources costing over $200 million a year is not only ethically unjustifiable but morally irresponsible, especially when such procedures can lead to serious injury and even death. Besides the possible harm the procedure can inflict on a child — which violates the basic tenet of … treating every person with dignity and respect — it also violates Medicaid’s mandate to be responsible stewards of medical resources. When millions of people in the United States and around the world lack basic health care, the provision of a non-therapeutic procedure — especially one that is unnecessary, costly, and in some cases fatal — is irresponsible and a violation of the moral law.” [4] References 1. Healy EF. Problems connected with surgery. In Medical ethics. Chicago, IL: Loyola University Press; 1956: 129. 2. Catechism of the Catholic Church. Mahwah, New Jersey: Paulist Press; 1994: 553. 3. Fadel P. Respect for bodily integrity: a Catholic perspective on circumcision in Catholic hospitals. Am J Bioethics 2003; 3(2): 1f-3f. 4. Clark PA. To circumcise or not to circumcise? A Catholic ethicist argues that the practice is not in the best interest of male infants. Health Prog 2006; 87(5): 30-9. Petrina Fadel Director, <a href="http://www.catholicsagainstcircumcision.org/" rel="noopener" target="_blank">Catholics Against Circumcision</a> <h3>Ignores African evidence: No consistency in relation between circumcision and HIV status</h3> Tobian and Gray advocate male circumcision (MC) for preventing the transmission of HIV and other sexually transmitted infections (STI’s). Their arguments are serious, but hide counter evidence much displayed in the past 20 years. There is no doubt that male circumcision has an effect on HIV and STI transmission during sexual intercourse. However, this does not guarantee a large population impact, which would be the only rationale for recommending its large scale use. In Africa, groups practicing and not practicing male circumcision have basically the same level of HIV seroprevalence some 25 years after the onset of the epidemic. This has been shown from well conducted large scale Demographic and Health Surveys (DHS), as well as from numerous studies based on selective groups. [1,2] MC has no long term impact because of repeated exposure, and does not confer any “protection” per se. The effect found in clinical trials is similar to that of a low-efficacy vaccine (as cholera vaccine), or that of a low efficacy contraceptive (as rhythm method), none of which being recommended on a large scale because there are much more efficient alternatives. Note that in the Uganda and South-Africa trials, the incidence of HIV in the circumcised groups was about 1% per year, which would lead to massive levels of infection after 30 to 40 years of sexual life. The argument about potential demographic impact or cost-effectiveness measured by mathematical models seems fallacious. Mathematical models are good as long as they predict the real world. This is the case for highly efficacious vaccines (measles), or highly efficacious contraceptives (pill, IUD), where mathematical models predict accurately the observed population impact. But in the case of MC, where is the mathematical model explaining the situation observed in Lesotho, Malawi or Tanzania, where the HIV seroprevalence is higher in the circumcised groups than in others? Where is the model explaining why the dynamics of the HIV epidemics is the same in circumcised ethnic groups than in others in South Africa? Likewise, the argument about the long term effect of newborn circumcision does not match what has been found in a long term study in Australia. [3] Condom use and safe behaviour are the only efficacious strategies to protect individuals and to control STI’s at population level. This policy can be implemented on a large scale, as exemplified by the case of Japan. References 1. Garenne M. Long-term population effect of male circumcision in generalized HIV epidemics in sub-Saharan Africa. African Journal of AIDS Research 2008; 7(1):1-8. 2. Van Howe, RS. Circumcision and HIV infection: review of the literature and meta-analysis. Int J STD&AIDS 1999; 10:8-16. 3. Millett GA, Flores SA, Marks G, Reed JB, Herbst JH. Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis. JAMA 2008; 300(14):1674-84. Michel Garenne Institut Pasteur, Epidemiologie des Maladies Emergentes, Paris <h3>Claims not supported by evidence from African circumcision trials</h3> Tobian and Gray [1] recommend that people making decisions about male circumcision in the US consider evidence from three randomized controlled trials (RCTs) in South Africa, Kenya, and Uganda, which reported that circumcision reduced men’s HIV incidence by 51% to 60%. This communication requests additional information from the Ugandan trial, [2] which was funded by the National Institutes for Health (NIH), and from a parallel trial of circumcision to protect men in Uganda, funded by the Bill and Melinda Gates Foundation (BMGF). [3] Tobian and Gray state “the protective efficacy of circumcision increases with time.” In fact, the evidence shows that the opposite. The NIH-funded Ugandan trial collected data relevant to that statement during follow-up visits after the RCT was stopped in late 2006. [4] To my knowledge, these data have not been reported separately, nor have data from the BMGF-funded trial been reported separately. However, all infections and person-years (PYs) of follow-up in both trials (the NIH trial to December 2006; the NIH trial after December 2006; and the BMGF trial) have been reported in combined form. [4] Subtracting date reported from the NIH trial to December 2006 [2] shows a net of 38 infections in 2,927 PYs during late follow-up in the NIH trial and in the BMGF trial. From these net data, circumcision reduced men’s risk for HIV by 42% – showing that protection waned over time among men in the NIH trial and/or less protection for men in the BMGF trial than in the other three trials. Other unreported evidence could inform continuing debates about circumcision’s impact on HIV transmission. Data reported from the Ugandan NIH trial to December 2006 suggest that non-sexual transmission was important: 16 of 67 men with incident HIV reported no partners (6 men) or 100% condom use (10 men). [2] Similar data are not available from later follow-up in the NIH trial or from the BMGF trial. The HIV-status of men’s partners is relevant to assess men’s risks. The BMGF protocol reports following more than 3,700 wives, including wives of men in the NIH trial. [3] But neither trial has reported the partner’s HIV-status for any man. Study teams have reported no information about blood exposures. Full report of collected evidence from these studies might improve our understanding of circumcision’s impact on men’s and women’s health, as well as adults’ risks for HIV infection in Africa. [5] References 1. Tobian AAR, Gray RH. The medical benefits of male circumcision. JAMA 2011; 306: 1479-1480. 2. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomized trial. Lancet 2007; 369: 657-666. 3. ClinicalTrials.gov. Trial of male circumcision: HIV, sexually transmitted disease (STD) and behavioral effects in men, women and the community. ClinicalTrials.gov identifier: NCT00124878, last updated on 9 August 2007. Washington DC: NIH, 2007. Available at: http://clinicaltrials.gov/show/NCT00124878 (accessed 25 June 2011). 4. Gray RH, Serwadda D, Tobian AAR, et al. Effects of genital ulcer disease and herpes simplex virus type 2 on the efficacy of male circumcision for HIV prevention: analyses from the Rakai trials. PLoS Med 2009; e1000187. 5. Gisselquist D. Randomized controlled trials for HIV/AIDS prevention among men and women in Africa: untraced infections, unasked questions, and unreported data. Social Science Research Network 2011. Available at: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1940999 (accessed 11 October 2011); and at http://dontgetstuck.wordpress.com/downloads/ (accessed 11 October 2011). David Gisselquist, independent consultant <h3>Claims about Human Papilloma Virus untrue</h3> Why did JAMA publish the recent commentary by Tobian and Gray when there is good reason to ignore their studies? When studying the impact of circumcision on human papillomavirus (HPV) infections, Tobian and Gray found a 35% reduction in the incidence of HPV in those randomized to early circumcision. [1] Unfortunately, the entire treatment effect can be attributed to sampling bias, as the researchers failed to sample the penile shaft where circumcised men are more likely to harbor the virus. [2] Similarly, the reduction in genital herpes infections, when properly adjusted for lead-time bias, is not statistically significant. [2] Their study found no association between circumcision and gonorrhea and a slight, non-significant increased risk of syphilis in those randomized to early circumcision. Their study on HPV transmission to women, whose husbands had been randomized to early or delayed circumcision, also has methodological flaws. The researchers made no attempt to determine the source of the infections, half of the women were infected at the beginning of the trial, infections were determined using an insensitive method, and 17% were lost to follow-up. Interestingly, condom use was associated with increased HPV incidence. For HPV 16 and 18, which account for 70% of cervical cancers, no difference was found based on the partner’s circumcision status. Consequently, their positive findings apply to viruses responsible for only 30% of cervical cancers. Studies from the United States have failed to confirm these flawed African studies. A prospective study of 603 female university students found no association between new HPV infections and circumcision status of the partner. [3] Similarly, in 477 male university students, there was no association between the incidence of HPV and circumcision status. [4] A national survey using a complex, stratified, multistage probability sampling design found that circumcision was not associated with herpes simplex virus type 2. [5] Fortunately, some of this discussion is moot, as effective HPV vaccines are currently available. It appears that JAMA is allowing well-financed zealots to promote their own unethical, poorly designed research. In the future commentaries should be also be carefully vetted for factual accuracy. References 1. Tobian AAR, Serwadda D, Quinn TC, Kigozi G, Gravitt PE, Laeyendecker O, et al. Male circumcision for the prevention of HSV-2 and HPV infections and syphilis. N Engl J Med 2009; 360: 1298-309. 2. Storms MR. Male circumcision for the prevention of HSV-2 and HPV infections. N Engl J Med 2009; 361: 307. 3. Winer RL, Lee S-K, Hughes JP, Adam DE, Kiviat NB, Koutsky LA. Genital human papillomavirus infection: incidence and risk factors in a cohort of female university students. Am J Epidemiol 2003; 157: 218-26. Erratta 2003; 157: 858. 4. VanBuskirk K, Winer RL, Hughes JP, Feng Q, Arima Y, Lee S-K, et al. Circumcision and the acquisition of human papillomavirus infection in young men. Sex Transm Dis 2011 (December); e-pub ahead of print. <a href="https://www.circinfo.org/news_2011.html#busk">See summary on this site</a>. 5. Xu F, Markowitz LE, Sternberg MR, Aral SO. Prevalence of circumcision and herpes simplex type 2 infection in men in the United States: the National Health and Nutrition Examination Survey (NHANES), 1999-2004. Sex Transm Dis 2007; 34: 479-84. Robert S. Van Howe, MD, MS, FAAP Clinical Professor, Department of Pediatrics and Human Development Michigan State College of Human Medicine Marquette, Michigan <h3>Ignores harm to women</h3> Imagine my surprise to see JAMA allow Tobian and Gray a commentary promoting the benefits of male circumcision while ignoring how their own research showed a 50% increase in HIV transmission to the partners of circumcised males. [1] Why would any ethical physician promote a procedure that will ultimately infect a greater number of females who will then infect their babies? Furthermore, infant circumcision has been shown to negatively impact the primal period by decreasing bonding and breastfeeding, [2] causing increased pain to the newborn because they lack inhibitory pathways, and imprinting violence onto their brains. [3] It is barbaric and unethical to cut off healthy, normal body parts on people without their consent. Parental rights do not trump basic human rights in such situations. Saying that infant circumcision prevents some unforeseen adult disease is like promoting mastectomies for infant females. It is ludicrous. The only thing circumcision prevents is normal sexual function. [4] What is particularly galling is that their studies are not only flawed with multiple biases, but they would never have been allowed in the U.S. because of the ethical red flags. [5] Tobian and Gray have moved Tuskegee to Africa, and Johns Hopkins continues to make millions off these unethical experiments using American taxpayers’ money. Tobian and Gray’s professional careers depend on promulgating the myth that male circumcision prevents HIV. Yet, they state they have no conflict of interest. Their impassioned pleas can only undermine their credibility, which can only be rescued by making their data public. Any reluctance to do so should be suspect. Michelle R. Storms, MD Northern Michigan University References 1. Wawer MJ, Makumbi K, Kigozi G, Serwadda D, Watya S, Nalugoda F, Buwembo D, Ssempijja V, Kiwanuka N, Moulton LH, Sewankambo NK, Reynolds SJ, Quinn TC, Opendi P, Iga B, Ridzon R, Laeyendecker O, Gray RH. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet 2009; 374: 229-37. 2. Howard CR, Howard FM, Weitzman ML. Acetaminophen analgesia in neonatal circumcision: the effect on pain. Pediatrics 1994; 93: 641-6. 3. Fitzgerald M. The birth of pain. MRC News 1998; (Summer): 20-3. 4. Frisch M, Lindholm M, Grønbæk. Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark. Int J Epidemiol 40.5 (October 2011): 1367-1381. <a href="http://sciencenordic.com/male-circumcision-leads-bad-sex-life">See news item at Science Nordic</a>. 5. Van Howe RS, Storms MR. How the circumcision solution will increase HIV infections. J Publ Health Afr 2011; 2(e4):11-5. <h3>Ignores flaws and limitations of African studies</h3> The commentary by Tobian and Gray placed too much importance on the results of their own and other randomized clinical trials (RCTs), which have serious problems with both internal and external validity. Internal validity problems include selection bias (only men willing to be circumcised were recruited), expectation bias, lead-time bias, duration bias (one of the studies found the protective effect began to disappear at 18 months and valid long-term follow-up was not possible), and attrition bias (205 men became infected, yet 703 were lost to follow-up). The studies were halted early, which, in studies with a small percentage having the outcome of interest, can result in marked overestimates of treatment effect and exaggeration of lead-time bias. There were also unexplained anomalies. Men who reported no unprotected sex accounted for 23 of 69 infections in the South African study and 16 of 67 infections in the Ugandan study. In the Ugandan study, men who consistently used condoms had a higher frequency of HIV infection than men who never used condoms (1.03 versus 0.91 per 100 person-years). The researchers made no attempt to determine the source of new HIV infections, so the number of sexually transmitted infections is unclear. The studies also lack external validity. [1] In African national surveys, HIV rates are higher in circumcised males for 10 of the 18 countries. [2] Subsequent African studies have failed to find an association between circumcision status and HIV. [3] There is a major problem when extrapolating the RCT results, conducted under highly sterile conditions with research-supported and supervised personnel, to the scale-up for African health care at large, in which shortages of personnel, sterile conditions, and equipment, would likely produce more infections. The men in the trials received continuous counselling, extensive education, free condoms, free health care, and high levels of compensation not available to other Africans. Extrapolating these results to infants in the United States is an even further unjustified leap. There are no studies of infant circumcision or of heterosexual males in the United States that support circumcision as a preventative for reducing HIV infection. With nearly 50 million Americans lacking health insurance, and poor children going without many basic services, it is ethically and morally inappropriate that Medicaid fund an unproven procedure. The focus should be on interventions that work. Abstinence, limiting the number of sexual partners, condom use, and testing for and treating HIV, are much better options to be pursued. [4] References 1. Green LW, Travis JW, McAllister RG, Peterson KW, Vardanyan AN, Craig A. Male circumcision and HIV prevention: Insufficient evidence and neglected external validity. Am J Prev Med. 2010; 39: 479-82. 2. Vinod M, Medley A, Hong R, Gu Y, Robey R. Levels and spread of HIV seroprevalence and associated factors: evidence from national household surveys. DHS Comparative Reports No. 2. 2009:209. 3. Heffron R, Chao A, Mwinga A, et al. High prevalent and incident HIV-1 and herpes simplex virus 2 infection among male migrant and non-migrant sugar farm workers in Zambia. Sex Transm Infect 2011; 87: 283-8. 4. Lima V, Anema A, Wood R, et al. The combined impact of male circumcision, condom use and HAART coverage on the HIV-1 epidemic in South Africa: a mathematical model. 5th IAS Conference on HIV Treatment, Pathogenesis and Prevention, Cape Town, abstract WECA105, 2009. John W. Travis, MD, MPH RMIT University, Melbourne, Australia <h3>Ignores principles of evidence-based medicine</h3> Tobian and Gray have cherry picked the medical evidence in favour of neonatal circumcision and ignored both arguments and evidence to the contrary. A similar exercise was performed in Australia last year by Cooper et al, [1] which received an immediate rebuttal in the circumcision policy statement released by the Royal Australasian College of Physicians, and so much additional criticism that the journal published eight letters in reply. [2] After an exhaustive review of the evidence the RACP found that “in low prevalence populations … circumcision does not provide significant protection against STIs and HIV,” and concluded that there was no medical case for neonatal circumcision. [3] A longer critique argued that the proposal was flawed because it ignored doubts about the African clinical trials and the interpretation of the WHO recommendations arising from them; was irrelevant to the specifics of Australia’s HIV problem; departed from the principles of evidence-based medicine; underplayed the harm and risks of circumcision; ignored basic principles of medical ethics and human rights; and was marred by unscientific thinking in describing circumcision as a “surgical vaccine.” [4] Tobian and Gray’s appeal suffers from the same flaws, the most serious of which is its violation of the principles of evidence-based medicine. Evidence of circumcision as an acceptable tactic from underdeveloped countries with high sero-prevalence and predominantly female to male transmission cannot be transposed to developed countries with low sero-prevalence and transmission predominantly in MSM or injecting drug users. Where is the United States evidence that uncircumcised men are at greater risk of HIV, and that circumcision without consent is an effective and ethically acceptable response? Evidence that circumcision of adult men has a protective effect against HIV cannot be extrapolated to children [5], and the same is true of the claim that the Africans experienced no loss of sexual sensation; circumcision in infancy may well have a different impact from circumcision after sexual maturity. Tobian and Gray assert that surrogate consent from parents overcomes the ethical and human rights problem because they can consent to vaccination. This hackneyed analogy fails because children are vaccinated against diseases that affect them as children and, unlike circumcision, it does not entail the amputation of a functional body part that the individual may appreciate. Children are not at risk of HIV or any other STIs: since there is no urgency to intervene we can safely wait until they are old enough to provide their own informed consent. References 1. Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV [editorial]. Med J Aust 2010;193:318-319. 2. “The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV” ... <a href="https://www.circinfo.org/MJA_Cooper_letters.html">and now the case against</a>. Med J Aust 2011;194(1)97-101. 3. Royal Australasian College of Physicians. Circumcision – RACP Position Statement. Sydney (AUST): RACP; 2010 September. 4. Darby R, Van Howe R. Not a surgical vaccine: There is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia. <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1753-6405.2011.00761.x/full">Aust N Z J Public Health 2011;35(5):459-465</a>. 5. Perera CL, Bridgewater FHG, Thavaneswaran P, Maddern GJ. Safety and efficacy of nontherapeutic male circumcision: A systematic review. Ann Fam Med 2010; 8 (1): 64-72. <a href="https://www.circinfo.org/newsindepth.html#benefit">See summary on this site</a>. Robert Darby Canberra, Australia NOTE: JAMA did publish an “edited” (i.e. censored) version of this letter; we publish the original, full version here. <h3>Circumcision commentary ignores risks</h3> In making their case for more explicit promotion of neonatal circumcision in the United States, Tobian and Gray cursorily dismiss or simply ignore the arguments against it, including such fundamentally crucial factors as the true range and incidence of risks. The claimed 0.2% to 0.6% neonatal complication rate is a falsely minimized representation of potential harm, already suspect due to the retrospective, short-term design of the source studies. Data exists to show, for example, at least a 1% risk of circumcised boys needing some kind of repeat surgery,(1) and up to a 20% incidence of meatal stenosis (found virtually only in circumcised males, and often requiring painful surgical correction).(2) Other real concerns left unacknowledged include the risk of circumcision-related MRSA infection,(3) and underreporting of rarer but catastrophic complications.(4) The United States does not, in fact, have in place any comprehensive system of prospective surveillance for adverse events following circumcision. The truth is that no one actually knows how many circumcised boys need to be rehospitalized, how many require specialist follow-up, IV antibiotics, or blood transfusions, how many lose part or all of their glans or penile shaft, or die due to circumcision complications, nor is there precise prospective data on the incidence of a host of other documented problems. But our lack of understanding of the scope of circumcision’s risks is not limited only to those problems directly associated with surgical outcomes. There is, in addition, little scientific knowledge of or attention paid to the possible harmful effects of genital cutting of children on later sexual functionality or emotional health.(5) Without such information, flatly, no valid risk-benefit comparison, cost-benefit analysis, or policy pronouncements can be made. Nor indeed, when deprived of such risk information, can any parent be said to be giving valid informed consent. Promoting circumcision for its potential benefits, yet with such a limited and inadequate analysis of it potential risks and harms – let alone its ethical problems – is scientifically unsupportable and ethically improper. References 1. Van Howe RS. A cost-utility analysis of neonatal circumcision. Med Decis Making 2004;24:584-601. 2. Joudi M, Fathi M, Hiradfar M. Incidence of asymptomatic meatal stenosis in children following neonatal circumcision. J Ped Urol 2011;7(5):526-8. Epub 2010 Sep 18. 3. Nguyen DM, Bancroft E, Mascola L et al. Risk factors for neonatal methicillin-resistant staphylococcus aureus infection in a well-infant nursery. Infect Control Hosp Epidemiol 2007;28(4):406-11. 4. Pediatric Death Review Committee: Office of the Chief Coroner of Ontario. Circumcision: A minor procedure? Paediatr Child Health. 2007;12(4);311-312. 5. Bollinger D, Van Howe RS. Alexithymia and circumcision trauma: A preliminary investigation. Int J Mens Health 2011;10(2):184-195. Gillian Longley RN, Colorado, USA <h2>Further objections to the circumcision solution</h2> <h3>Full of factual errors</h3> The new editor of JAMA needs to find a competent fact checker to assure that the commentaries published by the journal are factually accurate. A case in point is the recent commentary on the need for more infant circumcision by Tobian and Gray. Contrary to their article: 1. The California ballot initiative did not propose a “ban” on circumcision. 2. There are no observational studies in the United States (let alone a large number) which found that male circumcision reduces the risk of HIV infection in men. On the contrary, American studies show either that circumcision makes no difference, or that circumcised men (especially if Black) are at greater risk of HIV. A study by Sansom et al, actually cited by Tobian and Gray as though it supported their case, actually showed the lifetime risk of HIV among Black men to be 6.23% with 73% circumcised, yet a lifetime risk to Hispanics of only 2.88% and a circumcision rate of 42%. [1] This would suggest either that there is no connection between circumcision and reduced susceptibility to HIV; that circumcision increases the risk of HIV; or that being Black in the USA is a far greater risk factor for HIV than “lack of circumcision”. 3. Very few of the observational studies document the age at which the participants were circumcised. 4. Blacks in the United States do not have “the lowest rates of male circumcision” but have circumcision rates which are similar to or greater than the circumcision rates in whites. 5. Circumcision has not been shown to reduce the risk of cervical cancer. Even if it did, that is not a valid reason to circumcise infant boys. 6. The American Academy of Pediatrics recommends that decisions be delayed until the child is competent enough to provide fully informed consent. The age of this depends on the child, but is usually around 14 years of age. 7. Meatitis has repeatedly been shown to be more common in circumcised males. Two studies have shown that balanitis is more common in circumcised boys, especially in the first three years of life. There have been three studies that compared the rates of phimosis based on circumcision status: none of which found a significant difference. 8. The complication rate of 0.2% given by the commentators is from a typographical error in the abstract of a study that found a 2% risk of complications. [2] The 0.6% figure is from a letter to the editor [3] . Based on actual studies, the rate of immediate complications is 2% to 10%. The rate of meatal stenosis, which is a delayed complication, is between 5% and 20%. [4] 9. There is no evidence that complication rate of neonatal male circumcision is substantially lower than the complication rates of adult male circumcision. Two studies have directly compared neonatal circumcision to later circumcision. One found no difference in complications, one found a higher rate of complications for the neonate. 10. Sexual dysfunction has been documented in a national survey in Denmark and multiple other studies. These are not anecdotal reports. 11. Vaccines with only 30% to 60% effectiveness are rarely if ever promoted or used, especially when other less expensive, more effective, less invasive options are available. References 1. Sansom SL, Prabhu VS, Hutchinson AB, An Q, Hall HI, et al. Cost-effectiveness of newborn circumcision in reducing lifetime hiv risk among U.S. males. PLoS ONE 2010:5(1): e8723. doi:10.1371/journal.pone.0008723. <a href="http://www.plosone.org/article/comments/info%3Adoi/10.1371/journal.pone.0008723">Informative comment by Hanabi </a>at http://www.plosone.org/article/comments/info%3Adoi/10.1371/journal.pone.0008723. <a href="https://www.circinfo.org/Foreskin_owner_decide.html">See also comment on this site</a>. 2. Gee WF, Ansell JS. Neonatal circumcision: a ten-year overview: with comparison of the Gomco clamp and the Plastibell device. Pediatrics 1976; 58: 824-7. 3. Harkavy KL. The circumcision debate. Pediatrics 1987; 79: 649-50. 4. Joudi M, Fathi M, Hiradfar M. Incidence of asymptomatic meatal stenosis in children following neonatal circumcision. J Pediatr Urol 2011; 7: 526-8. <h3>Ignores functions of the foreskin</h3> Before recommending unlimited government funding of infant male circumcision, Tobian and Gray should at least make a good will effort to acknowledge the impact of amputating the prepuce. The prepuce is a specialized, pentalaminar, junctional tissue, similar to lips and eyelids, that has skin on the outer surface and a mucosal membrane on the inner surface. Near the transition of the inner and outer surface is a pleated region with an extremely high concentration of fine-touch neuroreceptors. This region, which contains nearly all of the penis’s fine-touch neuroreceptors, is removed in virtually all circumcisions. [1] By contrast, the glans is a neurologically dumb organ and contains primarily free nerve endings that transmit only deep pressure and pain. [2] When tested for fine-touch thresholds, the foreskin was found to be the most sensitive portion of the penis, which was more sensitive that the most sensitive portion of the circumcised penis, which was the circumcision scar. The glans in circumcised adult men was significantly less sensitive than the glans in men not circumcised. [3] Similarly, the vibrotactile thresholds of the glans increase significantly following circumcision. [4] Circumcision also severs the frenular artery and interrupts the blood supply to the ventral aspect of the urinary meatus. This results in scarring and narrowing meatus. Consequently, between 5% and 10% of males circumcised as infants will require a meatotomy to correct their acquired meatal stenosis. [5, 6] In absolute contrast to what is stated by Tobian and Gray, meatitis has been documented almost exclusively in circumcised males. In the nineteenth century the medical community adopted circumcision as a cure for masturbation. Physicians at the time recognized that if the most sensitive portion of the penis were removed, this might help decrease the temptation to masturbate. Circumcision has been failing to deliver the promises of its promoters ever since. References 1. Cold CJ, Taylor J. The prepuce. BJU Int 1999; 83 (suppl 1): 34-44. 2. Halata Z. Munger BL. The neuroanatomical basis for the protopathic sensibility of the human glans penis. Brain Res 1986; 371: 205-30. 3. Sorrells ML, Snyder JL, Reiss MD, Eden C, Milos MF, Wilcox N, Van Howe RS. Fine-touch pressure thresholds in the adult penis. BJU Int 2007; 99: 864-9. 4. Yang DM, Lin H, Zhang B, Guo W. [Circumcision affects glans penis vibration perception threshold]. Zhonghua Nan Ke Xue 2008; 14: 328-30. 5. Van Howe RS. Incidence of meatal stenosis following neonatal circumcision in a primary care setting. Clin Pediatr (Phila) 2006; 45; 49-54. 6. Joudi M, Fathi M, Hiradfar M. Incidence of asymptomatic meatal stenosis in children following neonatal circumcision. J Pediatr Urol 2011; 7: 526-8. <h3>Smacks of racism and sexism</h3> The commentary by Tobian and Gray suggests an underlying racism and sexism. Studies of circumcision were performed in Africa because they were not ethically permissible in the United States. HIV investigators in Africa have uniformly accepted the theory that the African epidemic is fuelled by frequent sexual contacts with multiple partners because it fits an unsubstantiated racial stereotype rather than the facts. This theory requires African men to have sexual contact with each of their partners on a daily basis to generate the current infection rates. [1] African men and women have been used as guinea pigs to fortify the American cultural practice of circumcision. In the most egregious of these studies, HIV infected men were randomized to circumcision or not. The HIV status of the participants was not disclosed to the participants or their female sexual partners. The female sexual partners were followed to determine how long it took for them to become HIV infected. Eighteen per cent of the women with circumcised partners became HIV infected and 12% of women with uncircumcised partners became HIV infected before the study was terminated. Amazingly, the researchers concluded that it was more important to circumcise HIV infected men so they could avoid stigmatization than to protect their female partners from the 50% increase in HIV infection risk. [2] In other words, they believe African women are dispensable. At least in Tuskegee, the men were no longer contagious. In 2009 Gray and colleagues suggested promoting circumcision primarily to blacks and Hispanics. [3] While HIV infections are concentrated in the economically deprived, Hispanics have a much lower prevalence of HIV and a much lower circumcision rate than blacks. This would suggest that circumcision in the economically deprived may increase HIV infection rates. Blacks actually have the highest circumcision rates in the U.S. and yet also have the highest HIV rates. Blacks have circumcision rates between 81% and 91%, depending on the decade of birth, which are similar or higher than the rates seen in whites. [4,5] Rather than admit circumcision has failed to protect black males from heterosexually transmitted HIV infection and focusing on more effective means of preventing HIV infection (such as condoms and anti-retroviral therapy), the commentators appear to think that some benefit may come from increasing an already high circumcision rate. This defies logic and suggests that there is a lingering fear of black sexuality. References 1. Sawers L, Stillwaggon E. Concurrent sexual partnerships do not explain the HIV epidemics in Africa: a systematic review of the evidence. J Int AIDS Soc 2010; 13: 34. 2. Wawer MJ, Makumbi K, Kigozi G, Serwadda D, Watya S, Nalugoda F, Buwembo D, Ssempijja V, Kiwanuka N, Moulton LH, Sewankambo NK, Reynolds SJ, Quinn TC, Opendi P, Iga B, Ridzon R, Laeyendecker O, Gray RH. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet 2009; 374: 229-37. 3. Gray RH, Wawer MJ, Serwadda D, Kigozi G. The role of male circumcision in the prevention of human papillomavirus and HIV infection. J Infect Dis 2009; 199: 1-3. 4. Xu F, Markowitz LE, Sternberg MR, Aral SO. Prevalence of circumcision and herpes simplex type 2 infection in men in the United States: the National Health and Nutrition Examination Survey (NHANES), 1999-2004. Sex Transm Dis 2007; 34: 479-84. 5. Mor Z, Kent CK, Kohn RP, Klausner JD. Declining rates in male circumcision amidst increasing evidence of its public health benefit. PLoS ONE 2007; 2(9): e861. <h3>Discriminates in favour of minority religions</h3> Tobian and Gray have suggested that Medicaid pay for the religious circumcisions of Jewish and Muslim boys. This clearly violates the separation between church and state as set up in the First Amendment of the Constitution. While the commentators use a selective bibliography to espouse their beliefs about the medical benefits of circumcision, parents do not circumcise their sons for some imaginary medical benefits, they circumcise them for cultural, cosmetic, and religious reasons. One could more easily argue that marriage is associated with improved health, including lower rates of STIs, and lower rates of HIV infections. If Medicaid is asked to pay for circumcisions for religious reasons, Medicaid should also be expected to pay for religious weddings. Why should Jews and Muslims get a benefit from the state that is not available to people of other religions? The commentators obviously did not think this through. It is not the role of the state to favor those with one set of religious beliefs over another. This is also a slap in the face of those from cultural or religious backgrounds who believe that they are required to have the genitals of their daughters cut. Over the past five years there has been increasing evidence in medical literature that cutting of female genitals may have medical benefits and minimal risks. [1-4] So, why focus only on boys, when girls could benefit as well? References 1. Stallings RY, Karugendo E. Female circumcision and HIV infection in Tanzania: for better or for worse?[abstract] Third International AIDS Society Conference on HIV Pathogenesis and Treatment. Rio de Janeiro, July 25-27, 2005. 2. Essén B, Sjöberg N-O, Gudmundsson S, Östergren P-O, Lindqvist PG. No association between female circumcision and prolonged labour: a case control study of immigrant women giving birth in Sweden. Eur J Obstet Gynecol Reprod Biol 2005; 121: 182-5. 3. Catania L, Abdulcadir O, Puppo V, Verde JB, Abdulcadir J, Abdulcadir D. Pleasure and orgasm in women with Female Genital Mutilation/Cutting (FGM/C). J Sex Med 2007; 4: 1666-78. 4. Applebaum J, Cohen H, Matar M, Rabia JA, Kaplan Z. Symptoms of posttraumatic stress disorder after ritual female genital surgery among Bedouin in Israel: myth or reality? Prim Care Companion J Clin Psychiatry 2008; 10: 453-6. <h3>Cavalier and selective attitude to the medical literature</h3> Tobian and Gray’s commentary on infant male circumcision refers to “anecdotal reports that male circumcision can cause sexual dysfunction.” This statement indicates that the commentators are either unfamiliar with or are purposely mischaracterizing the medical literature. Several small studies that documented a lack or improvement or decline in sexual function following circumcision in adult males circumcised for medical indications. [1] There are several studies, with the exception of two performed in Turkey, that have shown a higher rate of premature ejaculation in adult male who are circumcised compared to the non-circumcised. In one study of 207 men, premature ejaculation was nearly five times greater in circumcised adults (adjusted OR 4.88, 95%CI=2.35-10.15).[2] These are not anecdotal reports. In a study of 139 women who had sexual experience with both circumcised and non-circumcised men these women reported that sex with a non-circumcised partner had significantly less vaginal discomfort, a higher likelihood of vaginal and multiple orgasms, longer duration of coitus, and more positive post-coital feeling. On a rating scale between –10 and +10 these women rated coitus with circumcised men at an average of 1.81 and with non-circumcised men at an average of 8.03.[3] This study may have been influenced by a selection bias; however, a national health survey of 5552 adults in Denmark confirmed these findings. In this survey circumcised men reported a greater number of sexual partners and a greater rate of reporting frequent difficulties with orgasm (adjusted OR=3.26, 95%CI=1.42-7.47). Women with a circumcised male sexual partner reported greater rates of incomplete sexual fulfillment (AdOR=2.09, 95%CI=1.05-4.16), difficulties with orgasm (AdOR=2.66,95%CI=1.07-6.66), and dyspareunia (AdOR=8.45, 3.01-23.74).[4] A national survey is not an anecdotal report. The studies from Africa mentioned by the commentators need to be taken with a grain of salt. The participants in these trials were extremely well compensated by African standards, so both the Hawthorne effect and willingness to please the participant’s benefactors may have been in play. These studies focused on changes in overall sexual satisfaction, leaving readers uninformed about the actual levels of sexual satisfaction reported. The men in the study also reported implausibly high levels of sexual satisfaction. This suggests that the measure of sexual satisfaction used may not have been able to measure a difference if it existed. In the future it would be better if JAMA published commentaries written by individuals who are familiar with the medical literature and unwilling to mischaracterize it. References 1. Coursey JW, Morey AF, McAninch JW, Summerton DJ, Secrest C, White P, Miller K, Pieczonka C, Hochberg D, Armenakas N. Erectile function after anterior urethroplasty. J Urol 2001; 166: 2273-6. 2. Tang WS, Khoo EM. Prevalence and correlates of premature ejaculation in a primary care setting: a preliminary cross-sectional study. J Sex Med 2011; epub ahead of print. 3. O’Hara K, O’Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int 1999; 83 (suppl 1): 79-84. 4. Frisch M, Lindholm M, Grønbæk. Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark. Int J Epidemiol 40.5 (October 2011): 1367-1381. <a href="http://sciencenordic.com/male-circumcision-leads-bad-sex-life">See news item at Science Nordic</a>. <h3>Violates research and publications ethics</h3> One of the first ethical questions a new editor of a medical journal faces is, how does a journal deal with well-financed zealots who want to promote their own unethical, poorly designed research? It appears that for the new editor of JAMA that the answer is to give them open slather and silence any critical voices. In the last year Tobian and Gray have authored numerous opinion pieces to promote male infant circumcision in the United States. [1] Hot on the heels of their multi-million dollar NIH- and Gates Foundation-funded studies in adults, these researchers, turned lobbyists, are telling us that infants in the USA are really adults in Africa and need to be circumcised. Unfortunately, their enthusiasm is hollow and desperate, and their studies were unethical. Before their studies began, it was known that more effective, less expensive, less invasive methods for preventing HIV infection were available. To include humans in an experiment knowing that the intervention is inferior and more invasive than currently available options was clearly unethical. To follow HIV-infected men, without informing them or their partners of their infection status, to see how long it took before their female sexual partners became infected may be the most unethical study in several generations. It remains unclear how these clearly unethical studies were approved by the Investigational Review Board of Johns Hopkins or published by a well-respected journal such as The Lancet. The methodological shortcomings of the studies out of Johns Hopkins have been discussed in detail elsewhere and may explain why these studies lack external validity. [2,3] Finally, from reading Tobian and Gray, you would never know that there is a study on circumcision that does not list one of them among the authors. Such academic narcissism should not be encouraged, although it provides insight to the commentators’ motives. In 2005 certain sceptics suggested that circumcision advocates were studying circumcision and HIV in Africa as method of shoring up waning support for infant male circumcision in the USA [4] It looks like this prediction has come true. Readers of JAMA do not want to read unsubstantiated propaganda. Fresh on the job, and the new editor has already earned a failing grade. References 1. Tobian AAR, Gray RH, Quinn TC. Male circumcision for the prevention of acquisition and transmission of sexually transmitted infections: the case for neonatal circumcision. Arch Pediatr Adolesc Med 2010; 164: 78-84. 2. Garenne M. Long-term population effect of male circumcision in generalised HIV epidemics in sub-Saharan Africa. Afr J AIDS Res 2008; 7: 1-8. 3. Green LW, Travis JW, McAllister RG, Peterson KW, Vardanyan AN, Craig A. Male circumcision and HIV prevention insufficient evidence and neglected external validity. Am J Prev Health 2010; 39: 479-82. 4. Van Howe RS, Svoboda JS, Hodges FM. HIV infection and circumcision: cutting through the hyperbole. J R Soc Health 2005; 125: 259-65. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource JAMA censors circumcision critics darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>San Francisco bill will protect newborns, allow men the freedom to choose</h3> by Claire Vriezen Iowa State Daily, 2 March 2011 I must begin with acknowledging that by nature of being female, I am not as qualified as some to be addressing this issue. But as a human being, concerned with human rights, I am indeed allowed to comment. Citizens of San Francisco are <a href="http://www.sfmgmbill.org/Site/Home.html">working to pass a bill</a> that would outlaw male circumcision until the child reaches the age of 18. The bill would allow for exceptions if the procedure was deemed medically relevant, and the person performing the circumcision must be a medical practitioner where the procedure is performed. No exceptions will be made for those that desire their child to undergo the operation as a matter of custom or tradition. Although circumcision rates among male newborns has decreased in the past few years, <a href="http://www.drmomma.org/2010/08/us-circumcision-rate-falls-to-33.html">32 percent of male infants</a> are still having bits of their anatomy snipped off after leaving the womb. It baffles me how widely accepted this practice still is, despite it’s similarity to female genital mutilation. In both cases, young children or newborns are subjected to a procedure that removes part of their sexual anatomy — half the time <a href="http://www.ama-assn.org/ama/no-index/about-ama/13585.shtml">without anesthetic</a> — because their parents judge it to be acceptable. But isn’t it the job of the parents to know what is good for their children? Sure, for the most part. But when decisions result in the surgical removal of a normal, healthy part of anatomy, rationale must be called into question. There’s a reason the American Medical Association, as well as most of the medical community, term male circumcision as “non-therapeutic.” In many other developed countries — Canada, the Netherlands and other European countries — medical societies strongly recommend against routine circumcision of males. There is no immediate reason for the majority of male newborns to be circumcised. The main medically based argument for circumcision seems to be that it reduces the risks of sexually transmitted diseases and infections. Most commonly cited are studies that provide a positive correlation between higher HIV rates and lack of circumcision. The <a href="http://www.who.int/hiv/mediacentre/news68/en/index.html">World Health Organization</a> has decided the relevant research is compelling enough to recognize male circumcision as a way to reduce the risk of HIV infection, though others claim the studies conducted have exaggerated data and overlooked confounding factors. Regardless, this still does not provide a basis for circumcising infants. Is an infant expected to participate in sexual behaviors that could result in HIV exposure? I should hope not. Is circumcision the only way to reduce HIV risks? No. Condoms remain an effective way to combat HIV exposure and safe-sex education and practices are much preferred options when seeking to reduce STI rates. Perhaps an even more common defense of circumcision is the claim that it is a cultural or religious decision of the parents. This defense has even less basis than medically related evidence. To again make the comparison, female genital mutilation is a common cultural or religious practice in many African, Middle Eastern and Asian regions. Yet, we regard this act with disgust, and we pity the young girls forced to endure it. Research on female genital mutilation has even resulted in some reports linking it to lower HIV rates, but this does nothing to quell our horror. Certain cultural practices that result in the genital mutilation of an infant — male or female — should most certainly be subject to scrutiny. But what about those that desire to circumcise their child for religious reasons? The most obvious example is Judaism. Circumcision is required by Jewish law, so shouldn’t children born into Jewish families be circumcised? Freedom of religion allows people to practice what they want, right? This is true, up until the point where religion crosses ethical lines. There have been <a href="http://wwrn.org/articles/30951/?&place=united-states&section=health-medical">court cases</a> where the medical needs of the child violated the religious beliefs of the parents, and the courts tend to rule that the life and health of the child overrides the religious dictates of the parents. Religious circumcisions should follow the same guidelines. In this case, medically irrelevant amputation of the foreskin on an infant crosses similar ethical boundaries. If treating a child for disease overrides the religion of the parents, shouldn’t preserving the child’s anatomy fall under the same protection? I do not know whether the bill put forth in San Francisco will amount to anything, but I hope the decline of circumcision among newborn males continues. Infants need not be subjected to an undoubtedly painful procedure with dubious medical benefits. With only a third of the world’s male population circumcised, a good deal of men seem to be getting along just fine without the procedure. To promote male circumcision is to promote the marring of a normal body and to promote needless pain for newborns. If young men reach 18 and find they are willing to undergo the operation and become circumcised for whatever reason they choose, that is their prerogative. Whether they deem the alleged benefits valid or whether they have religious, cultural, or personal motivations, it should be their own decision to remove a part of their body, and no one else’s. <a href="http://www.iowastatedaily.com/opinion/article_0d2a9c86-43df-11e0-8971-001cc4c03286.html" rel="noopener" target="_blank">Full text with comments</a> <h3>Circumcision, genital mutilation must end</h3> by Ryan Holland The Daily Targum, 8 March 2011 Male circumcision is a deplorable act with an archaic founding and should not be allowed to continue. Jews believe in circumcision because of God's discussion with Abraham in Genesis. Abraham — who by the way was 100-years-old at the time — was told that any uncircumcised child will have his soul "cut off from his people" (Genesis 17:14). Similarly, Passage 16:123 in the Quran states that Allah wanted the Prophet Muhammad to live according to Ibrahim's faith. Noting that Ibrahim circumcised himself — with an axe, by the way — the prophet decided to continue the tradition. The fact that Jews, Muslims and followers of other religions believe in circumcision does not mean that it should be accepted. Some pious followers believe that AIDS was created to punished homosexuals or that women who have extramarital sex should be stoned to death. Just because these beliefs come from a religious background does not mean that they should be tolerated. Religion is a poor excuse for genital mutilation. It is not a hyperbole to describe circumcision as genital mutilation. The majority of men in this world and virtually all of male animals are uncircumcised. It does not appear as if they are any less healthy because of this. There is also arguably very little benefit to cutting off one's foreskin, and it is agreed upon by the medical community that there is no medical need to have one. Conversely, there are various downsides to the practice. For one, infections and even death can occur because of this unnecessary surgery. Hundreds of babies die every year because of complications related to circumcision. Furthermore, there is a noticeable sexual numbness that those with less foreskin experience. After circumcision, the glans become less sensitive, which impedes pleasure. Also, uncircumcised men declare that most of their sexual excitement comes from the foreskin — not the glans. By removing the foreskin along with all of its nerves, there is a significant decrease in the sexual experience. Many argue that the government should not be able to interfere with religious practices. That is a ridiculous generalization to make. Surely, it is okay for the United States to ban female circumcision or lashings for public intoxication even though these acts are based on religious doctrines. It is our responsibility as human beings to bring attention to great injustices. The act of circumcision for religious purposes is a very thinly veiled excuse to mutilate a baby's genitals. There is no medical need to have a circumcision, and it can in fact cause harm and even death. It also causes irreversible sexual damage. It is inexcusable to let this practice continue. What others think their god believes is meaningless when it comes to human rights violations. Circumcision and other forms of genital mutilation need to end. Thinking otherwise is disgraceful to our species. Ryan Holland is a School of Arts and Sciences sophomore majoring in cell biology and neuroscience at Rutgers University. <a href="http://www.dailytargum.com/opinions/circumcision-genital-mutilation-must-end-1.2508511" rel="noopener" target="_blank">Full text with comments</a> <h2> <a id="steam" name="steam"></a>American opposition to infant circumcision gathers steam</h2> A few months ago the proposal for a citizens’ ballot to place a legal prohibition on circumcision of male minors was regarded as yet another silly Californian whim that would get nowhere, but the success of the promoters in gathering sufficient signatures to put the proposal to a referendum has alarmed devotees of circumcision and aroused fierce editorials and mockery in the mainstream media - and of course the familiar accusation that the measure is motivated by anti-semitism. Conservatives now fear that the referendum may actually be passed, and are pulling out all stops in an effort to discredit the promoters. Despite the hostile media blitz, accusations of anti-semitism are difficult sustain when the proposal is aimed principally at the 50 per cent (approx) of American parents who circumcise their sons, 97 per cent of whom are not Jewish at all, and when it is supported by numerous Jewish men and women and has actually been given sympathetic coverage in quite conservative Jewish media, such as the Jewish Reporter. A recent edition carried a forceful article by Rebecca Wald (founder of the website <a href="http://www.beyondthebris.com/">Beyond the Bris</a>) in favour of the measure, which attracted an immense volume of comment (some hostile, much supportive) on the journal’s website. Another Jewish mother recently published a heartfelt critique of circumcision on the parenting forum <a href="http://www.babble.com/pregnancy/giving-birth/uncircumcised-baby-boy-infant-circumcision/">Babble.com</a>, explaining why she, as a Jewish woman, had decided that it was morally wrong to circumcise her sons: "Despite a [Jewish] cultural legacy of thousands of years, my husband and I did not circumcise our son ... Let’s keep American baby boys intact. It’s wrong to force an irreversible circumcision on a child when he is too young to decide for himself." <h3>Conservative Jewish site publishes op-ed praising circumcision ban measure.</h3> Questioning circumcision by REBECCA WALD The prospect of a circumcision ban sits poorly with many in America where parents enjoy relatively broad rights to raise their children as they choose. Jewish people are understandably concerned, fearing such restrictions would be discriminatory, hurtful, and violate religious freedom. However, as a Jewish person who opposes the genital cutting of all children absent medical necessity, I’m glad these measures are being considered. What’s best for children deserves continual assessment and, thanks to these proposals, that’s happening. My husband and I are both Jewish. We’re both American. Yet deciding to leave our son with the penis he was born with was not difficult. Causing pain to our beautiful child and forever changing his body didn’t seem right. We considered infant circumcision from different angles and concluded the surgery wasn’t in his best interest, either as a tender newborn or as the man he will become. In December I launched Beyond the Bris, a web-based project that is putting real faces and voices to the Jewish movement against infant circumcision. It is an open and dynamic forum where likeminded Jewish people can come together. We share our ideas with one another and visitors to the project in whatever ways feel right to us. This includes original music, poetry and art. I couldn’t be happier with the terrific response I’ve been getting from Jews in America, Israel and elsewhere who agree that children are entitled to keep their whole sex organs. Skim the recent headlines and you will likely read stories of Jewish outrage over the proposed circumcision bans in California. However this isn’t the full story. I recently spoke with Lloyd Schofield, the San Franciscan who spearheaded the effort to place the ban on the November ballot. He expressed to me his amazement about how open, interested and positive many members of the Jewish community have been about his efforts. He told me that when he was gathering signatures, many people self-identified as Jews and some signed his petition on the spot. Others declined, but even within this group he said all were respectful and many seemed genuinely happy to take educational handbills and learn more about the subject. I think the positive Jewish response to the Beyond the Bris project and to the efforts in California speaks tremendously of the Jewish people; that we are willing to seriously consider this issue even when it means challenging thousands of years of tradition. I can’t say I’m surprised. Jewish people have been integral in every rights movement in this country and this is no exception. Parents agreeing to cut their children’s healthy sex organs has occurred throughout history among diverse cultures. Groups that cut rationalize their behavior yet are quick to criticize other groups who modify the sex organs differently. I would encourage anyone who thinks along these lines to look into the anatomy of the natural versus the circumcised penis and what foreskin removal really is and does from an anatomical perspective. FGC is done for many of the same reasons as male infant circumcision including perceived cleanliness, preferred appearance, cultural and religious tradition and the prevention of disease. In recent years, FGC has even moved to modern hospitals, for those families who can afford it, and is performed by trained physicians. Medical studies have even “proved” FGC prevents sexually transmitted disease. It’s difficult to step outside of one’s culture and see it with perspective. For Jews in America and Israel I think it’s doubly hard to recognize our own brand of cutting as being harmful because it is both a cultural and a religious norm. But if you do the research and look at this issue in an openminded and intellectually honest way, it just might “click” that there’s something not right about infant circumcision. For me, once this shift happened, my perspective changed forever and I could no longer see it as just another parenting choice. Rebecca Wald, J.D., is the founder of the <a href="http://www.beyondthebris.com/">Beyond the Bris project</a>. She lives in Fort Lauderdale, Florida. <a href="http://thejewishreporter.com/2011/06/02/questioning-circumcision/" rel="noopener" target="_blank">Read full article and comments here</a> <h3>Why My Son Isn't Circumcised: One mother’s stance against infant circumcision by Jennifer Margulis </h3> My friend Peter, whose parents are Russian, grew up in America with an intact foreskin, as have all the men in his family for generations. But when he became sexually active the foreskin was so tight around the head of his penis that it did not retract easily. Peter’s condition has a name, phimosis, and if you Google “foreskin problems” you’ll find chat groups of young men experiencing similar difficulties asking for advice. Peter decided to be circumcised as an adult. Circumcision is part of my Jewish cultural heritage. All of my male relatives — my father, uncles, and three older brothers — have been circumcised. In the Bible, God commands Abraham to circumcise his male descendants. Practicing Jews hold a festive ceremony, called a bris, on the eighth day of a boy’s life during which the foreskin is removed either by a doctor or a mohel, a rabbi trained in circumcision. Even in countries where circumcision is not the norm, the majority of Jews choose to circumcise. Despite the problem he had with his foreskin, Peter — a nurse practitioner who advises thousands of patients a year on medical issues — decided not to circumcise his own son when the time came. Peter’s story in addition to the research I’ve done — witnessing the procedure firsthand, talking to men about their feelings — has convinced me that circumcision is not only unnecessary, it’s a painful and traumatizing procedure that should not be done in infancy. Although in England less than 5 percent of men are circumcised, in America my uncircumcised son is in the minority. According to an article in the New York Times, approximately 79 percent of all adult American males are circumcised. According to Intact America, a nonprofit organization trying to stop routine circumcision, circumcision is one of the most common surgeries performed in America, happening to over 1 million newborns a year, more than 3,000 times a day, once every 26 seconds. Every parent of an American boy faces a decision about circumcision, though the majority simply chooses to follow the doctor or hospital’s recommendation. Yet most American hospitals do not present circumcision as a choice, they simply assume that parents will opt to circumcise. When my friend Karen’s son, born in Atlanta, was a day old, a nurse bustled in with paperwork. “Ready for his circ?” the nurse asked. Karen looked at her husband. Patrick shrugged, “I guess so,” he muttered, and the baby was taken away. Karen and Patrick assumed the hospital was making the best choice for their child, but they had obviously never discussed it. Most parents do not watch their baby being circumcised and do not know that the procedure can be excruciatingly painful, even with anesthesia. Anyone who has ever witnessed a circumcision and heard the high-pitched scream of a newborn having part of his penis cut off (you can watch one on the internet if you don't believe me) knows that this surgery causes pain. "It’s wrong to force an irreversible circumcision on a child when he is too young to decide for himself.” Since the foreskin is attached to the head of the penis (also called the glans) like a fingernail is attached to the nail bed, in order to remove it has to be forcibly pried away. For the week or so that the cut is healing, a baby is peeing and defecating on a raw, open wound. Circumcision can be dangerous. This past March an Atlanta jury awarded $1.8 million in damages to a boy's parents after a seriously botched circumcision. It's also a procedure that can cause lasting regret. My cousin so laments being circumcised that he tries to dissuade the rest of the family from imposing it on our children. Although this is not a subject broached at cocktail parties, when men take the time to talk about having been circumcised, they often regret the loss of their foreskin. My husband is a good example. James had never really thought about being circumcised himself until our son was born six years ago. After reading up on the subject, he said: “I kind of feel cheated. I could have made my own decision as a teenager if my parents had left well enough alone.” He was horrified to realize that, in order for the penis to heal, the skin of the glans grows a covering, like a callous, to protect it. “It’s appalling. If I’d had the choice, I would have left my body as evolution left it, with functioning parts.” Other men feel similarly. An economist sent me this email: “Many say the anger only comes from botched surgeries, mine wasn’t. I’m hurt and upset about what happened to me as a baby boy and I have nightmares about it a few times a year. To be strapped to a board and violated like this is one of the most upsetting things that has happened to me in life... and I’m a cancer survivor as well.” Why circumcise a baby? The trend started in America in large part to keep boys from masturbating. Physicians writing in the 19th century even suggest the surgery should be done without medication so that a child will associate his genitals with pain. In Plain Facts for Young and Old (1882), John Harvey Kellogg writes: “A remedy [for masturbation] which is almost always successful in small boys is circumcision ...The operation should be performed by a surgeon without administering an anaesthetic, as the pain attending the operation will have a salutary effect upon the mind …” Like female genital mutilation, the idea was to make sexual sensations less pleasurable. Is that really what you want to do to your son? Today arguments in favor of circumcision are supposedly based on scientific research. Recent health studies in Africa suggest that circumcised heterosexual men are less likely to get HIV than non-circumcised counterparts, if they choose not to wear a condom. If they wear a condom, circumcision makes no difference. Proponents also argue that urinary tract infections are less likely, and that it is necessary for cleanliness. Yet the American Academy of Pediatrics (AAP) claims that the medical data in favor of circumcision “are not sufficient to recommend routine neonatal circumcision,” and most American doctors admit the procedure is not medically necessary. Given the AAP’s stance against recommending circumcision, why do some hospitals encourage or even pressure parents to circumcise? Of course they make money from the procedure, as they do from every medical intervention performed. But there may be another, much more nefarious reason: Human foreskin is used to manufacture artificial skin for burn victims and diabetics, as well as high-end cosmetics. “Where does the supply of foreskins come from?” my husband asks, looking disturbed. “Adult donors?” The male foreskin is not a superfluous body part; it protects the penis when a boy is a child and also plays a key role in female pleasure when a boy is a man. If there really is a correlation between circumcision and HIV prevention, then we should let adult men choose to have the procedure done once they decide to be sexually active. Despite a cultural legacy of thousands of years, my husband and I did not circumcise our son. If he chooses to get circumcised as an adult, either for a medical reason or to follow his cultural heritage, that’s his decision. Let’s keep American baby boys intact. It’s wrong to force an irreversible circumcision on a child when he is too young to decide for himself. <a href="http://www.babble.com/pregnancy/giving-birth/uncircumcised-baby-boy-infant-circumcision/" rel="noopener" target="_blank">Read full article and readers’ comments here</a> <h3>Infant circumcision: Abolish the unkind cut</h3> by Julie Van Orden, Salt Lake Tribune, 1 July 2011 In Loudon Wainwright III’s song “Men,” he says that men are treated as if they were expendable, fodder for wars and drowning ships. Women, in general, stay out of direct combat and join the children on the lifeboats. It is true that our culture expects men to sacrifice, fight, protect. We are not in the habit of reflecting upon where men — and boys — need help, concern, change. Our cultural blinders allow us to inflict upon men what would be considered atrocities if they were inflicted upon women. Nowhere is this more clearly evident than in the practice of circumcision. American girls are protected by federal law from the cutting and removal of even the slightest bit of their genitalia. Even a ceremonial “nick,” desired by some immigrant cultures, is outlawed. Of course, this is as it should be. Every girl, of every culture, should be able to keep her whole body intact. Yet, as the mother of both a daughter and a son, I have to ask: Why do we treat our boys differently? Why are boys’ bodies less valued in this way? Why is it OK to separate, slice, and sell off part of a boy’s body, often without anesthesia? (The selling of foreskins in America to biomedical companies is a million-dollar industry.) Is it inherent sexism? Is it because, as Wainwright suggests, we are just going to send them off to war anyway? Fortunately, many parents are realizing just how insane this practice is, and are leaving their sons intact, whole, and just the way that God and/or Mother Nature made them. They are saying “no,” loudly and clearly, to this barbaric cosmetic surgery. They are valuing their newborn sons just as they would their newborn daughters. The circumcision rate is plummeting. Informed parents realize that the risks of circumcision include shock, infection and death. Losing just 2 ounces of blood can be fatal for a newborn. Moreover, 18 states (including Utah) no longer use Medicaid dollars to pay for circumcision. Thus, I fully support the San Francisco ballot measure that would ban the sexist, outdated and harmful practice of routine infant circumcision. My son’s body is as valuable as my daughter’s. Codifying this into law is a civil rights movement of our time. <a href="http://www.sltrib.com/sltrib/opinion/52092520-82/circumcision-body-julie-newborn.html.csp" rel="noopener" target="_blank">Source: Salt Lake Tribune, 1 July 2011</a> <h2>Circumcision: Harm and Psychological Factors Ignored</h2> by Ronald Goldman, Bay Citizen (San Francisco), August 4, 2011 An initiative banning circumcision that was removed from San Francisco's November ballot stimulated a wave of articles related to the topic, but virtually all of them avoid discussing the inherent harm of circumcision. By defending or advocating circumcision, proponents avoid some of the emotional discomfort connected with questioning circumcision and fail to disclose the adverse effects. Consequently, they do not help us to see the whole picture. Psychological factors affect every aspect of the practice, including who chooses to study circumcision, what questions are studied and what questions are ignored; which studies are approved for publication and which studies are rejected; what circumcision information is communicated to parents and what information is withheld from parents; what recommendations are made by policy committees and what recommendations are ignored; and what circumcision information is reported in the media and what information is withheld from the public. Circumcision is a very misunderstood subject, and statements by "experts" may be misleading. National medical organizations unanimously find no proven medical benefit for circumcision. The endless search for a medical benefit―from treating epilepsy, irritability, and masturbation in the late 1800s to preventing sexually transmitted diseases today―has always been suspect. Studies show that circumcision is significantly painful and traumatic. Some infants do not cry because they go into shock. After circumcision infants exhibit behavioral changes, and there are disruptions in mother-child bonding. Changes in pain response of circumcised infants have been demonstrated in baby boys at six months of age, evidence of lasting neurological effects and a symptom of post-traumatic stress disorder. Anesthetics, if used, do not eliminate circumcision pain. Circumcision also has about two dozen surgical risks including, in rare cases, death. Some doctors and nurses refuse to perform or assist with circumcisions because of ethical considerations. Long-term harm is also a consideration, but circumcised American researchers also typically avoid the discomfort of studying the sexual and psychological harm (e.g., erectile dysfunction) associated with circumcision. This pro-circumcision bias in American medicine reflects the pro-circumcision bias in American culture. The United States is the only country in the world that circumcises many of its male infants for non-religious reasons. Europeans think we’re crazy. Americans generally ignore the fact that the loss of the foreskin matters. Most circumcised American men (and doctors) do not know what they are missing. Based on recent reports, circumcision removes up to one-half of the erogenous tissue on the penile shaft. The adult foreskin is a double layer, a movable sleeve equivalent to approximately twelve square inches. Medical studies have shown that the foreskin protects the penile head, enhances sexual pleasure, and facilitates intercourse. Cutting off the foreskin removes several kinds of specialized nerves and results in the thickening and progressive desensitization of exposed erogenous tissue as men age. This tissue would normally remain sensitive because it would normally be protected by the foreskin. Some men who are circumcised as adults (usually because they followed the questionable advice of a doctor) report a significant decrease in sexual pleasure as a result. For example, having sex after being circumcised has been compared to "seeing in black and white instead of in color." Some dissatisfied men report wide-ranging psychological consequences of circumcision including anger, a sense of loss and sadness, and sexual anxieties. Reduced emotional expression and the avoidance of intimacy may also be related to circumcision. Most circumcised men may seem satisfied because they accept cultural beliefs about circumcision and may not understand what circumcision is and the benefits of the foreskin, they may suppress certain feelings about circumcision because they are too painful, or they may not disclose these feelings due to fear of being dismissed or ridiculed. We have not had the courage to admit we are making a very serious mistake by continuing to circumcise. For American society, circumcision is a solution in search of a problem, a social custom disguised as a medical issue. Defending circumcision requires minimizing or ignoring the harm and producing overstated medical claims. Beware of circumcised American medical doctors who defend or advocate circumcision. Instead, watch a circumcision video and trust your feelings, instincts, and common sense. You will certainly want to keep your baby safe and intact. Ronald Goldman, Ph.D. (psychology) is executive director of the <a href="http://www.circumcision.org/">Circumcision Resource Center</a> and author of Circumcision: The Hidden Trauma and <a href="http://www.jewishcircumcision.org/book.htm">Questioning Circumcision: A Jewish Perspective</a>. <a href="http://www.baycitizen.org/blogs/citizen/circumcision-harm-and-psychological/" rel="noopener" target="_blank">Source: The Bay Citizen, 4 August 2011</a> <h2>The case against circumcision</h2> by Matthew Taylor, Mondoweiss blog, August 4, 2011 Alan Dershowitz's flippant, dismissive remarks about male genital mutilation (aka circumcision) are infuriating, but an apropos Freudian slip. From where I sit, military Zionism shares a lot in common with this barbaric practice. Both involve inflicting violence against an oppressed victim without regard to his/their wishes, rendering the oppressed a voiceless object, an 'It' as opposed to a 'Thou.' I'm 37, and have been sitting on a mountain of grief and rage for 17 years, since I discovered what was stolen from me while reading a critique of circumcision in a hip, underground, alternative Jewish newspaper I found at a campus Hillel, of all places. Most circumcision advocates don't know the first thing about what a foreskin is and what its purpose is in human sexuality. Did you know that a foreskin increases pleasure for both a man and his partner? Did you know that a foreskin contains tens of thousands of fine touch nerve receptors found nowhere else in the male genitalia, covers and protects the head (glans) of the penis, and creates a pleasure-inducing gliding mechanism? Did you know that circumcision removes the most sensitive and pleasurable parts of the male penis? Most adult circumcised men I've spoken to are reluctant to discuss this topic and get highly defensive about it, saying, "Hey, my penis is perfectly fine. My sex life is great." If you don't have a foreskin, you don't know what you're missing, Tricking yourself into thinking your sex life is all it could be (when it's not) is a very bad reason to continue inflicting this cruelty on future generations. Think of it this way: if there was a ritual surgery performed at birth that removed a child's ability to see in color, the world would still be beautiful in black-and-white. But why should your son's ability to see in color be taken away just because yours was? Sex in black-and-white is good, but sex in color is much better. It's well documented that one of the primary drives for circumcision, in both Jewish and gentile communities, was to dampen sexual pleasure. Moses Maimonides, the famed medieval Jewish rabbi, physician and philosopher, wrote, "One of the reasons for circumcision is to bring about a decrease in sexual intercourse and a weakening of the organ in question." Shouldn't that choice be left to the man whose body it is, not inflicted upon him when he's a defenseless baby? Much like military Zionism, circumcision is promoted on the back of a load of bald faced lies. Consider "a land without a people for a people without a land." Its analogs are "circumcision makes the penis cleaner," "circumcision reduces your chance of catching an STD," and the shopworn "God commands us to do this" (just like God allegedly promised us this land exclusively, and ordered us to ethnically cleanse it of non-Jews.) None of these statements are true, and I shudder at the necessity of debunking them, but debunk them I must, as I can only assume many readers of this blog have been brainwashed about circumcision as I was as a child, and are perhaps reading a rebuttal of the myths for the first time. "Circumcision makes the penis cleaner" - Let's apply some common sense here. Virtually no European men are circumcised. Is there rampant gangrene in Europe? No. Intact male genitals are as easy to clean as a female's. "Circumcision reduces your chance of catching an STD" - Again, Europe and common sense are our allies. Why is it that in uncut Europe, STD rates are lower than in circumcised America? Regardless, are infants at risk of catching STDs? Shouldn't decisions about how to practice safe sex be left to grown men? Condoms and responsible sexual choices prevent STDs, not genital mutilation. "God commands us to perform circumcision" - In the Torah, God also commands us to stone people to death, burn animal sacrifices, and take slaves from neighboring nations. Jews have given up those unholy practices, why shouldn't we give this one up too? The majority of Swedish Jews are intact, and guess what? They're still Jewish! Judaism, whether a cultural, ethnic, or religious identity, does not require circumcision. Jewishness is solely defined by parental lineage or conversion, not by genital cutting. Today, there are Jewish baby welcoming ceremonies for all genders free from genital cutting. In addition to significantly reducing a grown man's capacity for sexual pleasure, circumcision is a highly risky, unnecessary surgery that results in over 100 infant fatalities every year in the U.S., and leaves countless others with highly disfigured genitals in so-called "botched" circumcisions. In one famous case, David Reimer committed suicide because of his grief over his lack of a penis, the result of a botched circumcision. My entire argument boils down to one thing: It should have been my choice, and it should be the choice of every man/boy whose body it is -- not the parents. I have no objection to a man who's reached the age of consent choosing circumcision or any other permanent body modification for himself. But that choice must be preserved, not stolen. Parents who defend circumcision by saying "It's a personal choice" – I encounter that argument all the time in my work as an intactivist – are quite delusional to think they should have the right to choose to amputate healthy tissue from a non-consenting minor. They wouldn't do that to their daughters, why should they have the right to inflict such a human rights violation on their sons? I stand against sexual abuse, child abuse, genital mutilation, and torture, all of which are accurate – and I meant that logically, according to the precise dictionary definitions of those terms – descriptors of the anachronistic practice euphemestically called 'circumcision.' The very fact that our culture is so proud of judging African tribes as barbaric for practicing 'female genital mutilation,' while the mainstream media never uses the term 'male genital mutilation' to describe what routinely happens here, says a lot. Hint: In Europe, they think we're as twisted and barbaric as we think the tribes in Africa are. Fortunately, circumcision rates are falling in the U.S., from a peak of higher than 80% in the 1970s to around 33% today. According to a 1996 U.S. federal law, it is illegal to perform any act of genital cutting on a non-consenting minor female, even variants of circumcision that are far less invasive and damaging than the typical male circumcision. It's illegal in this country to even prick a clitoral hood and draw a tiny drop of blood from a baby girl for religious purposes, or for any purpsose! I want to see the same legal protections extended to baby boys. In San Francisco, efforts are underway to ban circumcision within city limits, although unfortunately a judge struck it from the ballot - I hope that an appeal will be successful. I see the anti-circumcision movement as being where the gay rights movement was 40 years ago, and I hope it doesn't take that long to catch up. The organized Jewish community presents a significant barrier to this effort, just as they do in the quest for Palestinian rights. Back to Mr. Dershowitz. He said: "And the first thing you have to do is have all these guys who are circumcized demand it back, go to the hospital, and have it sewn back on. That’ll make them complete pricks, instead of the pricks that they are, O.K.?" If I could sue the doctor who cut me (unfortunately I'm past the statute of limitations), or wave a magic wand and regenerate what I lost, believe me I would. But since I can't do either of those things, I'm restoring. It doesn't give me back everything that your allies in the penis mutilation industry stole from me, and it doesn't provide justice for the crime, but it does make a big difference. And I'll tell you what Mr. Dershowitz, circumcision has something in common with military, apartheid Zionism: both belong in the dustbin of history. Someday – someday! – Palestinians and Israelis will live together as equals, and someday baby boys will enjoy the same human rights baby girls already do in this country, namely, freedom from non-consensual genital cutting. I wonder if your fear that we'll ask for our foreskins back is an analogue to your fear of ethnically cleansed Palestinians demanding their right of return. (An aside: The fact that circumcision is widely practiced by Muslims, American gentiles, and others doesn't let Dershowitz and his pro-mutilation allies off the hook. Worldwide, 75% of men are intact, putting the circumcision camp in a dwindling minority.) For more info, <a href="http://matthewtaylor.net/foreskinresources.htm">check out my resources page</a>. P.S. - Mr. Dershowitz, if you're reading this, I challenge you to a public debate about circumcision. I'll win. All I need is one legal, constitutional argument: it's called Equal Protection. Thus, if this law were ever challenged at the Supreme Court level, it would have to be amended to outlaw male genital mutilation, too. Maybe you'd get used to Brit Shaloms instead, I hear they're quite enjoyable for everyone involved - especially the baby. <h2>Circumcision decision is only for consenting grown-ups</h2> by Amanda Windsor, The Times-Standard (USA), 9 September 2011 Genital cutting as a medical procedure rather than as a ritual sacrifice got its start as a Victorian fad treatment for masturbation. They blamed masturbation for many of the serious illnesses they could not understand or treat. A lot of Americans of my generation don't know this, but the foreskin is the most sensitive erogenous zone on the male body, and cutting it off was seen as a convenient “cure” for this problem of pleasure. Other treatments involved chastity belts and burning the head of the penis with hot pokers. I'll quote one of the fathers of medical genital cutting, Dr. John Harvey Kellogg "A remedy for masturbation which is almost always successful in small boys is circumcision, especially when there is any degree of phimosis. The operation should be performed by a surgeon without administering anesthetic, as the pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment, as it may well be in some cases. The soreness which continues for several weeks interrupts the practice, and if it had not previously become too firmly fixed, it may be forgotten and not resumed.” The same “benefits” were also recommended for girls, and clitoridectomies (removal of the clitoris) were also performed. But even Dr. Kellogg thought circumcision was inappropriate for infants and could lead to problems later. Nevertheless, as more births began happening in hospitals instead of at home, attended by doctors instead of midwives, the procedure began to be performed on infants more and more often. After World War II, doctors in all other industrialized nations rejected circumcision as harmful and unnecessary, but the U.S.A. followed a different path. Wartime military policy, the medicalization of childbirth, the adoption of a for-profit medical system instead of a public health service, and the opinions of popular figures such as Dr. Spock all played a role. Today the United States is also beginning to abandon the practice. Circumcision rates in the United States have dropped as low as one-third in recent years. I'm thrilled! Circumcision permanently removes 50 to 75 percent of a person's healthy erogenous tissue, is very painful, and has all of the same human rights issues as cutting girls and all of the risks that come with any surgery. What about those HIV results in Africa? The media likes to talk about a 50 percent risk reduction, and that sounds impressive, until you look at the numbers and discover that the risk was reduced from 3.38 percent to 1.58 percent. Not so exciting, and for each new study the benefit goes down; original studies suggested that cut men were eight times less likely to get HIV. Skeptical scientists suspect that when all the outside factors have been thought of and accounted for, there will be no benefit at all. These sorts of minuscule results are why no medical association in the world, not even in the U.S., recommends the surgery to prevent disease. I'll quote the American Medical Association: ”... behavioral factors are far more important risk factors for acquisition of HIV and other sexually transmissible diseases than circumcision status, and circumcision cannot be responsibly viewed as 'protecting' against such infections.” Ladies, would you cut off half or more of your happy parts for a reduction in your disease risk that's no better than the risks from the surgery? Would you like someone to surgically alter you to make you look just like your mother? Would you rather amputate your sensitive bits than go to all the work of washing them? Maybe you would. Hey, everybody's different, and I'm down with that. But maybe you wouldn't, and maybe it's time that guys have that freedom of choice too. Let's face it. Genital cutting is only for consenting grown-ups. A 2006 report estimated 100 neonatal circumcision-related deaths occur annually in the United States from anesthesia reaction, stroke, hemorrhage, and infection. A newborn has to be among the worst candidates for an unnecessary surgery. It's true that estimates of the annual number of deaths vary widely, everywhere from 2 to 2,000. Data on the number of injuries and unintentional amputations is also difficult to nail down. I can't wait for the number to certain: zero. <a href="http://www.times-standard.com/guest_opinion/ci_18802784" rel="noopener" target="_blank">Times Standard (Eureka, California), 9 September 2011</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Recent articles in the American press darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> The United States federal law criminalising any form of female genital cutting was passed by Congress as an addition to the U.S. Cade Title 18, Crimes and Criminal Procedures, and listed in Part I, Chapter 7, “Assault”. In other words, it categorises female genital cutting as an assault. The most relevant paragraph reads: "(a) Except as provided in subsection (b), whoever knowingly circumcises, excises, or infibulates the whole or any part of the labia majora or labia minora or clitoris of another person who has not attained the age of 18 years shall be fined under this title or imprisoned not more than 5 years, or both." Sub-section (b) allows the operation to be performed if it is “necessary to the health of the person on whom it is performed, and is performed by a person licensed in the place of its performance as a medical practitioner”. Source: <a href="http://law.justia.com/codes/us/2011/title-18/part-i/chapter-7/section-116/">18 U.S.C.A. § 116. Female genital mutilation</a> Congressional Findings Justifying the passage of the law, Congress advanced the following arguments: The Congress finds that: <ol> <li>the practice of female genital mutilation is carried out by members of certain cultural and religious groups within the United States;</li> <li>the practice of female genital mutilation often results in the occurrence of physical and psychological health effects that harm the women involved;</li> <li>such mutilation infringes upon the guarantees of rights secured by Federal and State law, both statutory and constitutional;</li> <li>the unique circumstances surrounding the practice of female genital mutilation place it beyond the ability of any single State or local jurisdiction to control;</li> <li>the practice of female genital mutilation can be prohibited without abridging the exercise of any rights guaranteed under the first amendment to the Constitution or under any other law; and</li> <li>Congress has the affirmative power under section 8 of article I, the necessary and proper clause, section 5 of the fourteenth Amendment, as well as under the treaty clause, to the Constitution to enact such legislation.</li> </ol> Section 645(a) of Div. C of Pub.L. 104-208 Why these observations would not apply just as strongly to circumcision of a boy is not obvious. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource US FGM law reflects cultural prejudice, not physical or ethical realities darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> The policy statement on circumcision (i.e. non-therapeutic circumcision of normal male infants and boys) released in September 2012 by the American (i.e. United States) Academy of Pediatrics is meeting a growing chorus of disapproval, rejection and ridicule. Child health experts in Europe and Canada; paediatricians and human rights lawyers in the United States; and a medical historian in Australia have all recently condemned the policy statement for failing to respect the bodies and advance the best interests of the very group that the AAP is (supposedly) dedicated to protecting - that is, children. If the AAP is not there to promote the best interests of children, what is it there for? <h3>European child health experts</h3> In an article published in the AAP house journal Pediatrics, child health experts from Austria, Britain, Denmark, Estonia, Finland, Germany, Iceland, Latvia, Lithuania, Norway, Sweden, the Netherlands, Canada, the Czech Republic, France and Poland have condemned the statement as unbalanced, tunnel-visioned, ignorant, wrong on many medical issues, and grossly inadequate in the all-important areas of medical ethics and human rights. The abstract of the article states: The American Academy of Pediatrics (AAP) recently released its new technical report and policy statement on male circumcision, concluding that current evidence indicates that the health benefits of newborn male circumcision outweigh the risks. The technical report is based on the scrutiny of a large number of complex scientific articles. Therefore, while striving for objectivity, the conclusions drawn by the eight task force members reflect what these individual doctors perceived as trustworthy evidence. Seen from the outside, cultural bias reflecting the normality of non-therapeutic male circumcision in the US seems obvious, and the report’s conclusions are different from those reached by doctors in other parts of the Western world, including Europe, Canada, and Australia. In this commentary, a quite different view is presented by non-US-based doctors and representatives of general medical associations and societies for pediatrics, pediatric surgery and pediatric urology in Northern Europe. To these authors, there is but one of the arguments put forward by the AAP that has some theoretical relevance in relation to infant male circumcision, namely the possible protection against urinary tract infections in infant boys, which can be easily treated with antibiotics without tissue loss. The other claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts and penile cancer, are questionable, weak and likely to have little public health relevance in a Western context, and do not represent compelling reasons for surgery before boys are old enough to decide for themselves. Source: Morten Frisch et al, Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision. Pediatrics 131, April 2013 <a href="http://www.circumstitions.com/Docs/aap-12-europe.pdf" rel="noopener" target="_blank">Full text may be downloaded as a PDF from Circumstitions.com</a> See also the analysis by High Young, <a href="http://www.circumstitions.com/news/news55.html#aap-europe2">AAP task force reveals cultural bias while denying it</a> <h3>Dissent in the United States</h3> In the United States itself, a clinical professor in pediatrics and a human rights lawyer have condemned the policy as culturally biased and invalidated by its neglect of such crucial issues as the anatomy, physiology and functions of the foreskin, the harm and complications of circumcision, and whether the removal of body parts from healthy children can be justified within accepted principles of medical ethics and human rights. Writing in the Journal of Medical Ethics, pediatrician Robert Van Howe and lawyer J. Steven Svoboda argue that the AAP ignores so many important topics that it is hard to know where to begin the critique. Svoboda says: “For example, the anatomy and function of the foreskin are not mentioned. The AAP’s circumcision recommendations contradict its own bioethics policy statement, which requires pediatric care to be based only on the needs of the patient. Non-therapeutic circumcision is incompatible with widely accepted ground rules for surgical intervention in minors. When physicians decide whether to do a procedure, they must, and normally do, exclude from their medical decisions non-medical factors regarding the parents’ culture. Contrary to what the AAP suggests, doctors are not cultural brokers. Their duty is promoting and protecting the health of their patients, not following practices lacking a solid ethical and medical foundation.” Van Howe and Svoboda accuse the AAP of cherry-picking articles that support circumcision, and of taking passages out of context from within articles that do not support it. They conclude that male circumcision should be neither recommended to parents nor funded by government insurance systems. Abstract: The American Academy of Pediatrics recently released a policy statement and technical report on circumcision, in both of which the organisation suggests that the health benefits conferred by the surgical removal of the foreskin in infancy definitively outweigh the risks and complications associated with the procedure. While these new documents do not positively recommend neonatal circumcision, they do paradoxically conclude that its purported benefits “justify access to this procedure for families who choose it,” claiming that whenever and for whatever reason it is performed, it should be covered by government health insurance. The policy statement and technical report suffer from several troubling deficiencies, ultimately undermining their credibility. These deficiencies include the exclusion of important topics and discussions, an incomplete and apparently partisan excursion through the medical literature, improper analysis of the available information, poorly documented and often inaccurate presentation of relevant findings, and conclusions that are not supported by the evidence given. Source: J. Steven Svoboda and Robert Van Howe, Out of step: Fatal flaws in the latest AAP policy report on neonatal circumcision. Journal of Medical Ethics, online first, 18 March 2013 <a href="http://www.circumstitions.com/Docs/aap-12-svobodavanhowejme.pdf" rel="noopener" target="_blank">The full article may be downloaded as a PDF from Circumstitions.com</a> See also the analysis by Hugh Young, <a href="http://www.circumstitions.com/news/news55.html#aap-jme">AAP Circumcision Task Force fails again</a>, 24 March 2013 <h3>Australian medical historian finds United States circumcision obsession puzzling and rather ridiculous</h3> Viewing the controversy from Australia, medical historian Dr Robert Darby considers the flaws of the new AAP policy in a updated version of The Sorcerer’s Apprentice –– his analysis of the United States obsession with circumcision, published as an e-book on Amazon. Dr Darby notes that the AAP has never released a policy on guns or firearms, and wonders how many American boys are killed or injured each year in firearms accidents. Does the AAP think that foreskins are a greater risk to child health than firearms? If not, why have a policy on circumcision but nothing on gun control or firearm safety? He writes in the preface: This short book is a revised and much expanded version of an article originally published in Contexts, magazine of the American Sociological Association, invited to coincide with the publication of my history of the rise and fall of circumcision in Britain (A Surgical Temptation) in 2005. An expanded version was published on my website (www.historyofcircumcision.net). Apart from a few references, that book did not cover the rise of circumcision in the United States, though it was the persistence of the practice there and its rather slow decline in Australia that led me to study the British experience in the first place. For this version I have further revised the essay and expanded it to include an explanation for the efforts to revive claims as to the “health benefits” of routine circumcision that began to appear in the early 1990s, and an examination of the climax of this trend in the latest policy statement on circumcision issued by the American Academy of Pediatrics in September 2012. Non-therapeutic (routine) circumcision of male infants and boys has always been an anomalous practice, defying all the normal rules of evidence-based medicine, biomedical ethics and surgery. Although evidence-based medicine requires that treatments be based on proof of the intervention having a direct net benefit (in the promise-of-benefit/risk-of-harm calculus) for the recipients, most of the evidence for the prophylactic (disease-preventing) effects of circumcision are applicable to adult men and even adult women, not to the male infants undergoing the surgery. Recognised authorities on biomedical ethics hold that no treatment is permissible without the informed consent of the subject; that treatments must always observe the principles of autonomy, non-maleficence, beneficence, proportionality and justice; and that surrogate consent (for incapable subjects, such as infants and the disabled) is valid only when clearly in the subject’s best interests or – when it involves amputation of body parts – in life-threatening situations. In the normal course of events, surgery is regarded as appropriate only when there is a pathological condition requiring surgical treatment; unnecessary surgery is rightly regarded as cosmetic (or even bad) surgery, and prophylactic removal of healthy tissue and body parts has never become part of the medical mainstream – except in relation to tonsils (briefly) and foreskins. Because tonsils have no psychological, sexual or cultural significance, it proved far easier to drop routine tonsillectomy than to abandon circumcision. On a world scale, routine circumcision has never attracted widespread support; it has always been a controversial and contested operation, with a vast and inconclusive literature, as enthusiasts and advocates endeavoured to make a convincing case against the foreskin. As I write this preface, the polarisation of opinion has reached a new pitch, further demonstrating that there is no consensus on this issue. In the United States medical authorities have just overturned forty years of disapproval by announcing that although the “health benefits” of circumcision are not great enough to recommend it as a routine, they are sufficient to allow parents to decide for their children and for medical insurance schemes to pay for it. In the Netherlands, by contrast, the Royal Dutch Medical Association has issued a powerful statement rejecting circumcision, warning that it is not merely of no medical value to children, but that it infringes their right to bodily integrity. In Germany a court has found that non-therapeutic circumcision constitutes bodily harm and is thus unlawful. In Australia the Tasmania Law Reform Institute has recommended that it be legally prohibited in most cases, with limited exemptions for religious practice. In Helsinki an international conference heard many speakers defend the right of all children to bodily integrity, and criticize unnecessary genital surgeries of all types, whether performed for medical or cultural reasons, and whether on boys, girls or intersex children. Never before have American health officials been so out of step with world opinion – and indeed, with informed opinion even in their own country. Within a few days of the publication of the latest circumcision statement, vigorous, well-argued critiques had appeared on numerous websites and blogs. Even the New York Times, usually the most rabidly pro-circumcision newspaper on earth, greeted the statement with the headline “Benefits of circumcision SAID to outweigh the risks”, suggesting that it was not entirely convinced. To give a flavour of the debate, I have included the commentary from the Seattle-based group, Doctors Opposing Circumcision, as an appendix. European rejection of the practice reminds us that routine circumcision was a strictly Anglophone phenomenon, generated in the late Victorian period when understanding of disease processes was primitive, there were few effective treatments, medical ethics were non-existent, masturbation (i.e. any pleasurable touching of the genitals) was regarded as both a disease and a moral crime, and children were not considered to have any rights at all. Times have changed, but less so in the United States than elsewhere. While Britain gave up circumcision in the 1950s, New Zealand in the 1960s, Australia in the 1970s-80s and Canada in the 1990s, the practice remained entrenched in the United States and probably did not reach its peak until the 1960s. Statements against the practice regularly issued by the American Academy of Pediatrics as from 1971 had little impact. It was one of those sad situations, like the mess caused by the sorcerer’s apprentice, where it proved easier to start a habit than to give it up it, and surprising, when so many other pre-modern shibboleths have gone by the board, even the taboo against homosexual behaviour. Americans today seem more comfortable with the idea of gay men having sex together and even marrying each other than with the prospect of uncircumcised heterosexual men having sex with their wives and girlfriends. How has it come about that Americans are more afraid of foreskins than of homosexuals? Why does a nation that prides itself on its individualism and love of freedom remain so keen on this mark of uniformity and submission? In this short essay I cannot provide a comprehensive answer to these question, but I hope at least to raise the principal headings under which an explanation may be found. We shall see that it has far more to do with culture, religion, tradition, power and economics – in short, the desires of adults – than with the health and happiness of American children. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Child health experts ridicule American circumcision policy statement darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> The percentage of male newborns who are circumcised in United States hospitals has dropped drastically. Over a 32-year period, the number of male newborns circumcised in the hospital decreased nationally to 58.3 percent in 2010 from 64.5 percent in 1979, according to new data from the Centers for Disease Control and Prevention. But while that 10 percent decrease over all is statistically significant, the authors of the report say, what leaps out of the data is a 37 percent drop in the West. In that 13-state part of the country, the rate of newborns receiving routine circumcisions at birth fell to 40.2 percent in 2010, by far the lowest rate in the country, from 63.9 percent in 1979. That decline accounts for virtually all of the shift nationwide. The authors cannot explain why the numbers dropped so precipitously in the West, which comprises Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington and Wyoming, because the analysis did not factor in contextual data. But it remains an intriguing question. Why would that part of the country differ so much from the rest? Have parents there developed a new attitude toward circumcision and, if so, why? The high-profile 2010-11 attempt to get a bill criminalizing the procedure on a San Francisco ballot might have provided an opportunity for opponents of the procedure to reach parents. The initiative — called the Prohibition of Genital Cutting of Male Minors — was ultimately quashed, but it did get 12,000 supporting signatures. “San Francisco is a bastion for new thinking and individual rights, which draws many people to the region; however, the entire West Coast — Washington, Oregon — also have very low infant circumcision rates,” said Lloyd Schofield, the leader of the San Francisco movement. “Certainly much of this comes from basic awareness and less insistence on the procedure from the medical industry.” Mr. Schofield said that “a huge driver of the decline” was the nonpayment for the procedure by private insurers, “but in particular coverage was removed from Medicaid here decades ago.” “When the money is gone,” he said, “it no longer serves a purpose … funny thing about that!” Douglas Diekema, a member of the American Academy of Pediatrics’ task force on circumcision and a professor of pediatrics at Seattle Children’s Hospital, echoed Mr. Stern’s theory that the difference in circumcision rates could be a result of demographics, but he had another theory, too. “The West Coast has more immigrants from populations that don’t circumcise as commonly as we do in the U.S.,” he said. “The Hispanic culture is one of those, and since the West and Southwest are taking on more Hispanics, one could assume there would be a drop.” At the same time, Dr. Diekema said, West Coast residents tend to be more progressive. “Ever since the founding of this country, the West Coast has attracted people who walk to the beat of their own drummer,” he said. “People here are more likely to question the standard and go a different way.” Source: Hope Reeves. <a href="http://parenting.blogs.nytimes.com/2013/08/22/circumcision-rates-in-u-s-drop-drastically-in-western-states/?_r=1">Circumcision Rates in U.S. Drop Drastically in Western States</a>. New York Times. New York Times, 22 August 2013. Note: Dr Diekema makes some interesting admissions. First, that the disposition to circumcise is primarily a cultural question, not a medical question at all. Secondly, that the decision not to circumcise is a sign of progressive attitudes and independent thinking. What does that say about people – like him – who favour circumcision? The other big question is why the incidence in the central and north-eastern states has remained steady. Perhaps Mr Schofield’s suggestion holds the key: that it is all about whether routine circumcision is covered by Medicaid (government health insurance). Perhaps this explains why the AAP circumcision report is so keen for circumcision to be a billable procedure. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Sharp decline in circumcision rates in western US states darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> An ominous sign of the growing American disenchantment with circumcision is an increasing number of papers and theses by young undergraduates and graduate scholars who are taking a very critical this hitherto taken-for-granted practice. A few years ago, it was only members of the dedicated anti-circumcision movement who were carrying out research into the history, medical rationalisations and bioethical aspects of circumcision; today we find papers being given at mainstream academic conferences, and theses written by under- and post-graduate students at prestigious universities. Recent theses by Shemuel Garber and Chris Jones are summarized here. <h2>The circular cut: Jewish and American circumcision practiced anatomised</h2> A well-researched by an American undergraduate, Shemuel Garber, particularly considers the practice of circumcision among the Jewish people, and as justified and practised by American medical authorities today. He writes in the introduction: Genital cutting has been around for so long that nobody knows when or why it began, though speculation abounds. Today, both male and female genital cutting are commonly practiced by various cultures in various regions of the world. Presently, all forms of genital cutting are almost universally regarded with disgust and often even moral indignation in the West. All forms, that is, but one. Male circumcision, a procedure in which the prepuce (or “foreskin”) of the penis is severed from the rest of the penis, permanently exposing the penile glans, is commonly practiced as a religious rite by Muslims and Jews and is routinely (though certainly not universally) practiced for non-religious reasons in the United States of America. I have a bit of personal experience with circumcision that, for the purpose of full disclosure, I will presently relate. As an infant, I, like many boys born in American hospitals, was circumcised shortly after my birth as a matter of routine. For just over a decade, my penis underwent no further marking by civilization. Then, when I was eleven, I converted to Judaism. Since my prepuce was long gone, circumcision was not an option. In order to initiate pre-cut male converts like me into the covenant between the male descendants of Israel and God, Jewish law stipulates a ritual called hatafat dam brit. To execute this sacred task on the day of my conversion, the mohel (ritual circumciser) politely asked me to lower my pants sufficiently provide access and then proceeded to stab my penis with a hypodermic needle, collect a little blood on a piece of gauze, and show it to three witnesses. Surprisingly, this was not my last encounter with a mohel. A few months later, I learned that the Cleveland orthodox community did not consider my conversion to be valid since they did not consider the rabbi who had conducted it to be sufficiently orthodox. I had to do everything including hatafat dam brit once again. Although from God’s perspective it was apparently much more kosher the second time around, everything was basically the same from my perspective, except that the mohel used a scalpel instead of a hypodermic needle. For the record, the scalpel hurt a bit more, though it was nothing a brave and consenting convert couldn’t handle. On July 21, 2012, I thought about circumcision critically for the first time at the Freies Museum in Berlin. A German lady to whom I had just been introduced broached the subject, wanting to know my opinion on whether Jews and Muslims should be allowed to circumcise their young in Germany. When I expressed my belief that they should have this right in name of religious freedom, she promptly informed that the question was not one of religious freedom at all, but rather a question of the rights of the child, rights, which she insisted, were violated by those who circumcised unconsenting children. My view, she asserted, was prejudiced by growing up in a country which this barbaric practice is commonplace. Troubled by these unexpected remarks, I spent the next several days reading about the debate over the legality of circumcision that was raging in Germany and trying to formulate my own opinion. Eventually, I realized that I had found a thesis topic. I went into the research with an open mind. All I knew for sure was that I was very confused. Over time, however, I developed a strongly oppositional opinion on circumcision. This opinion certainly comes through in my analyses. I sincerely attempt to argue fairly throughout the work, avoiding unnecessarily hyperbolic claims and honestly engaging with opposing views where appropriate, but I am not a disinterested observer and I make no claim to objectivity. Garber understands the essential point: that circumcision is not favoured because the medical evidence supports it, but because cultural commitment to or faith in circumcision generates the medical evidence that seems to provide a justification for it. Consequently, as one reason for circumcision loses its force (prevention of masturbation, epilepsy or hip joint disease), others take their place. He also understands that it is only because circumcision is performed on the most culturally, physically and sexually significant site of the male body – his penis – that it escapes the normal rules of surgery, evidence-based medicine and bioethical principles. As he explains with a telling thought experiment in chapter 2: Michael Katz writes with regard to the medical justifications for male circumcision that “There is no parallel in other prophylactic measures, such as immunization. No other prophylactic measure attempts to achieve a benefit by abrogating a natural process.” The point is that even if the prophylactic claims are true, they come at too high of a price. He also points out that, over time, the medical justifications for circumcision have changed while the recommendation has remained the same. As each new set of claims is discredited, another pops up to replace them. The medical community attempts, time and time again, to retroactively provide justifications for a ritual that is already culturally sanctioned. Were it not already culturally sanctioned, the medical arguments would not be accepted or, perhaps, put forth at all. The problem is not that it is inconceivable that a prophylactic effect could arise from the amputation of a functional body part. Rather, the problem is precisely that, in the absence of prejudicial cultural influence, the possibility would never be explored for obvious ethical reasons. A hypothetical example will help demonstrate this point. A freethinking American biologist contemplates America’s tragic obesity epidemic. After several minutes of deep reflection, he comes up with an idea. In order to prevent future generations of Americans from becoming grossly overweight,infants will be subjected to a relatively minor surgical procedure that inhibits their capacity for olfaction. Mind you, it will not eliminate their capacity for olfaction altogether. It will just reduce it enough so that the experience of flavor is moderated to a level that is more nutritionally adaptive in the context of today’s superabundance in the availability of calorically rich foods. If one were to conduct trials, one would likely be able to demonstrate that those who had undergone the procedure are significantly less likely to develop obesity and all of the medical conditions that are associated with it. Furthermore, after a few decades, one might be able to establish rigorous procedural standards that ensure that operative complications (like accidentally eliminating olfaction altogether) are reduced to nearly negligible levels. The essential point is that, even in light of these empirical demonstrations and technical advances, the practice would be rejected as intrinsically and essentially harmful. A reasonable critic would surely say, “If you are concerned about your child’s weight, then teach him about proper nutrition and stock your kitchen with produce rather than junk food. Don’t resort to damaging his sense of smell. That’s unethical!” If an American is truly concerned about his or her son getting HIV, the appropriate course of action would be to give him condoms and explain how using them consistently nearly eliminates the possibility of sexual transmission of HIV and to explain the dangers of intravenous drug use. Whether or not circumcision effectively reduces rates of HIV transmission or any other ailment, it should not be considered as a routine prophylactic measure because it is inherently harmful. Shemuel Toviah Garber. The Circular Cut: Problematizing the Longevity of Civilization’s Most Aggressively Defended Amputation. Thesis submitted to the faculty of Wesleyan University in partial fulfillment of the requirements for the Degree of Bachelor of Arts with Departmental Honors from the College of Letters and with Departmental Honors in Philosophy. Middletown, Connecticut: April 2013. <h2>The façade of inevitability: The AAP’s rhetorical strategies unmasked</h2> In “The facade of inevitability”, an MA thesis from Iowa State University, Chris Jones takes a cool and highly critical look at the policy statement on circumcision issued by the American Academy of Pediatrics in August 2012. He presents a provocative argument that, contrary to the AAP’s claims, it is not an objective scientific assessment, but an exercise in rhetoric and persuasion. While the AAP claims it is merely providing information to assist parents to make a decision, in reality the policy is nudging them, not so subtly, in making a decision in favour of circumcision. The significance of Jones’ thesis is wider than the specifics of his argument, for he is really declaring that the emperor has no clothes. The AAP likes to regard itself as the pre-eminent world authority on all matters relating to the health of children; according to this unimpressed graduate student, it is nothing more than a professional interest group with an ideological axe to grind. Jones writes in the introduction: The scientific issue I will focus on in this thesis is infant male circumcision (IMC) in the United States. A series of clinical trials conducted in sub-Saharan Africa (Kenya and South Africa) between 2003 and 2006 indicate that circumcision of males may prevent the transmission of HIV by as much as 60%. While the research was conducted on adult males in a region where an estimated 68% of the 34 million people living with HIV reside and where the infection rate among adults is a staggering 5% (AVERT), the American Academy of Pediatrics (AAP) has relied heavily on this research to justify their support of infant male circumcision (IMC) in the United States where less than 4% of the world’s HIV cases occur and where only an estimated .4% of the population are infected with HIV (CDC). The AAP indicates that recent research shows that the medical benefits of IMC outweigh the risks and that this justifies “access to this procedure for families who choose it” (756). What remains unclear is how this HIV research is used and applied to a vastly different context as a form of argument. The report focuses heavily on the ability of the family to make choices for their infant, but constructs a narrative of risk – primarily the risk of contracting HIV that makes the decision not to circumcise medically negligent. The report also displays an unresolved tension between the right of the family to make such a decision and the right of the child to make that decision once they reach the age of consent. My goal in this research is not to suggest that circumcision is right or wrong, only to examine how the technical report functions as a rhetorical artifact. What is particularly interesting about this document is that on a surface level it seems to merely suggest that parents have an opportunity to choose whether or not to have their children undergo the procedure, but a closer analysis reveals that the report is really arguing that circumcision is a better option. Because the primary audience of the report is the medical community (physicians, pediatricians, nurses, etc.), it is important to note that the technical report on male circumcision is available for free on the AAP’s website and was published both online and in the September 2012 issue of their journal. Given the immediacy and intensity of news coverage the policy statement received, it is reasonable to assume that a number of people viewing the report were parents or expecting parents. For this reason, the report is treated as having a pluralistic audience. A quick scan of articles touting the medical benefits of IMC or blasting the credibility of these claims will reveal a host of prevalent issues, and a review of commentary on such articles indicates just how intense this debate can be. The discourse that envelops the IMC issue has existed in the public sphere for a number of years, but more than ever medical research is being viewed by a public that may or may not be equipped to interpret it. In addition, this particular scientific discussion concerns both religious and cultural practice. Still, medical organizations like the AAP have a vested interest in presenting recommendations based on their evaluation of current research. The AAP is an organization “dedicated to the health of all children” (AAP History). Founded in the 1930’s by a cohort of medical professionals, the goal of the organization was to foster relationships within the medical community and between the medical community and other organizations. Their current mission is to “attain optimal physical, mental, and social health and well-being for all infants, children, adolescents and young adults” (AAP Facts). From a practical standpoint, the AAP helps to establish standards for preventative care of children such as immunization and diet. While the percentage of circumcised infant males in the United States has been declining in recent years (Rabin), there remains a need to regularize and medicalize the procedure due to the inconsistencies with how, when, and where the procedure is performed. From a number of viewpoints – human rights, religious rights, cultural ideology, socioeconomic, medical, etc. – infant male circumcision occupies a complex discursive web. In this paper I argue that the AAP maintains that the choice to circumcise should be left to the family of the infant, but they also inhibit this choice by both positioning the physician as the primary decision maker and by constructing a rhetoric of risk in regards to HIV infection. What looks like only a recommendation that circumcision should be an option for parents is really a suggestion that circumcision is a vastly better decision. In general, the AAP and their report (among other things) act to regulate the practice of circumcision and in doing so position those who choose not to circumcise as dissenters. By stating that it is better, from a medical standpoint, to have infant males circumcised, the AAP divides families into those who make good choices and those who do not. In chapter two I use cluster criticism to explore the discursive patterns of the technical report, and use recent theories about agency and kairos in chapter three to see how risk is constructed. In chapter four I use Latour’s model of the circulatory system of scientific facts to help to illuminate aspects of the AAPs 2012 technical report and how the report functions at a more macro level. I conclude that for a true choice to exist, we as a culture must understand and confront the social constraints that make not being circumcised unnatural. Chris Jones. The façade of inevitability: Risk, agency, and the American Academy of Pediatrics’ technical report on male circumcision. A thesis submitted to the graduate faculty in partial fulfillment of the requirements for the degree of MASTER OF ARTS. Iowa State University, 2013. <a href="http://lib.dr.iastate.edu/etd" rel="noopener" target="_blank">Available as PDf from Iowa State University</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Young American scholars turn critical eye on circumcision darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>New “circumcision guidelines” show that Centers for Disease Control ignores medical evidence</h3> After seven years of argument and paper shuffling, the bureaucrats in the glass towers that house the United States Centers for Disease Control have decided to follow the American Academy of Pediatrics in affirming that the benefits of circumcision outweigh the risk of complications. Although this was the headline conclusion of the AAP’s 2012 policy statement, it was an arbitrary assertion that did not follow from the evidence. Since the AAP was unable to quantify either the risks or the benefits of circumcision, it was logically impossible for them to reach such a conclusion. Even more seriously, as Brian Earp points out below, complications are only a small part of the story: for a non-therapeutic procedure involving the amputation of a significant body part it is not enough to assess the risk of complications (bleeding, infection etc); it is also necessary to factor in the value of that part and the harm of losing it. There is abundant evidence that men like having a foreskin, and thus that it removing it - especially if it is done without consent from an infant or child - is not quite the same thing as amputating a gangrened finger. The failure of both the AAP and the CDC to consider such a fundamental aspect of the circumcision decision means that their policies and guidelines are fatally flawed at their core and of little practical value. The CDC has made its draft guidelines available for public comment; as the early critiques published below suggest, it is likely to receive a lot of flak over the next few weeks. What is it with these Americans? <h2>Harm of circumcision and value of foreskin ignored</h2> Comment by Brian Earp on the proposed guidelines concerning male circumcision to be issued by the United States Centers for Disease Control Several people have asked for my take on the provisional CDC guidelines announced today suggesting that the benefits of male circumcision outweigh the risks. What follows is a brief, preliminary comment, in which I highlight just a few of the key issues: (1) The Centers for Disease Control (CDC) is largely following the American Academy of Pediatrics (AAP), whose statement I have already criticized here. Note that I have included some other professional critiques of the AAP documents in my post: the upshot is that the findings of the AAP were not taken seriously by the majority of its peer organizations in Europe, whose assessment of the AAP was that it exhibited cultural bias in favor of circumcision due to the status of circumcision as a routinized norm in this country. (Circumcision was absorbed into the medical establishment of the United States in the late 1800s in an effort to combat masturbation, among other dubious reasons, and then became preserved over time as a rationalized habit -- long past the time it was effectively abandoned by other developed nations). The CDC appears to be making the same mistakes, in part by misapplying the same - or similar - data to incommensurate epidemiological environments (i.e., by relying on studies carried out on adults in Sub-Saharan Africa to make recommendations concerning infant circumcision in the United States). It also falls flat in its (meager) ethical analysis in much the same way as the AAP did in 2012. For more on the AAP, the science of circumcision, and the attendant ethical issues, see my discussion here. See this recent paper well. (2) The CDC is using the wrong formulation for assessing the prudence of circumcision, namely benefit vs. risk. Benefit vs. risk was designed for therapeutic procedures (sometimes referred to as "medically necessary" surgeries), where it must be shown that the benefits to the patient outweigh the risk of surgical complications. In the case of circumcision performed on healthy individuals who cannot—if they are minors—consent, however, the appropriate test is not benefit vs. risk, but rather benefit vs. harm. Here, “harm” includes not only the risk of surgical complications (an elusive figure, due to the poor quality of the existing data), but also the inherent harm of having a functional, erotogenic genital structure removed in the absence of either disease or deformity. In legal theory, at least, unnecessary surgeries that amputate healthy tissue are considered to be harmful per se. On this view, the loss of the tissue is in itself a harm, unless the tissue can be shown either to have no value or to serve no functions, neither of which can plausibly be demonstrated in this case. Since there is no disease present, and since any future diseases to which the tissue may one day fall prey can be avoided and/or treated through non-surgical means, an additional harm concerns the loss of choice, in light of alternative risk-management options, concerning an extremely personal part of one's anatomy. The CDC glosses over all of this, however, and appeals (again) to an entirely inappropriate heuristic for non-therapeutic surgeries, according to which “surgical risk” is deemed to be the only morally-relevant cost to circumcision. (In its technical report, the CDC does point out that one advantage of adult circumcision, compared to infant circumcision, is that the former can be done autonomously, while the latter is always done without consent -- and may therefore lead to later resentment. This observation has not received much attention in the ongoing flurry of media coverage.) (3) Let me make one last point by way of a thought experiment. Suppose it could be shown that removing the labia majora of infant girls reduced their risk of getting urinary tract infections (since there would be fewer folds of moist genital tissue in which bacteria could find a home), as well as cancers of the vulva (since there would be less tissue in which such cancers could develop). It's not implausible, and in fact in countries in which female genital cutting is culturally normative, it is easy to find “medical” support for these views: female circumcision is often thought to be “more hygienic” and well as more aesthetically pleasing: therefore, it is often said, it is in the best interests of the girl child to be circumcised so that she can attain these benefits. Remember, female circumcision falls on a spectrum, and some forms of it are less invasive than male circumcision, may not involve modification of the clitoris, and are sometimes done for reasons other than (attempted) control of sexuality. Nevertheless, it is actually illegal in Western countries to conduct the very research by which such "health benefits" could be discovered. Non-therapeutic, non-consensual surgeries carried out on the genitals of healthy girls—no matter how slight or under what material conditions—are defined as impermissible mutilations in Western law. This is because it is presumed that girls are entitled to grow up with their genitals intact, and to decide, at an age of understanding, whether they would like to undergo permanent alterations to their private parts, and if so, for what reasons, and what kind. Whether a minor reduction in the risk of certain infections or diseases (whose prevalence is determined by socio-behavioral factors much more than anatomical-biological factors, and whose occurrence can typically be prevented and/or treated in much more conservatives ways) is worth the trade-off of losing one's labia (let’s say) -- or indeed one’s foreskin -- is a complex question, and one whose answer is likely to be highly subjective. Therefore, it should be up to the affected person to decide about permanent genital-modification surgeries at such a time as he or she can factor in his or her own preferences and values. Circumcision (of boys or girls) is not an effective health-promotion strategy, given less ethically problematic alternatives. Brian D. Earp, University of Oxford, 2 December 2014 Brian D. Earp is a <a href="http://blog.practicalethics.ox.ac.uk/author/brian-earp/" rel="noopener" target="_blank">Research Fellow in Ethics</a> at the University of Oxford. He holds degrees from Yale, Oxford, and Cambridge universities, including an M.Phil. degree in the history, philosophy, and sociology of science and medicine, focusing on male and female genital surgeries. Brian has served as a Guest Editor for the Journal of Medical Ethics, editing a <a href="https://www.circinfo.org/Journal_of_medical_ethics_July13.html" rel="noopener" target="_blank">special issue on the topic of childhood circumcision</a>, and has published widely in the leading journals in his field. <a href="https://www.academia.edu/9603843/Brief_comment_on_the_proposed_guidelines_concerning_male_circumcision_to_be_issued_by_the_CDC" rel="noopener" target="_blank">Proposed CDC guidelines on male circumcision: A critique (with links)</a> Circumcision risks and harms outweigh benefits: Now published as Brian Earp. <a href="http://journal.frontiersin.org/article/10.3389/fped.2015.00018/abstract" rel="noopener" target="_blank">Do the benefits of male circumcision outweigh the risks? A critique of the proposed CDC guidelines</a>. Frontiers in Pediatrics 3 (18), 21 February 2015 <h2>Why the Centers for Disease Control can’t get their facts straight</h2> <h3>Statement by Intact America</h3> Intact America, an organization that opposes the forced genital cutting of babies and children, sharply criticizes the recent Centers for Disease Control (CDC) proposed guidelines for circumcision. The CDC is calling for doctors to tell the parents of male infants, children and adolescents that circumcision has been found to reduce the transmission to men of HIV and other sexually transmitted infections (STIs). The guidelines were released on December 2, 2014, opening a public comment period that will end on January 16, 2015. “Beyond stating and restating its support for medically unnecessary circumcision, the Centers for Disease Control fails to provide any solid evidence to bolster the case for circumcision as a valid measure for disease prevention,” said Georganne Chapin, an attorney and executive director of Intact America. “The studies cited by the CDC purporting to show that circumcision reduces transmission of STIs were conducted in poor rural areas of sub-Saharan Africa over eight years ago. These studies have never been replicated elsewhere—let alone in the United States—and have no relevance to children or men in the developed world.” “There have been no systematic studies conducted anywhere about the short-or long-term adverse consequences resulting from circumcision," says director Chapin. "Through thousands of personal stories from boys, men and their parents we know that circumcision causes myriad complications, some requiring surgical correction. Adult consequences include poor body image, painful sex, psychological problems, and erectile dysfunction. The CDC's continued persistence in recommending what they know to be an unnecessary surgery is questionable. It is happening in the face of increased public awareness about circumcision’s harms, declining U.S. circumcision rates, and the growing reluctance of states and insurers to pay for this medically unnecessary surgery.” Intact America notes that the CDC’s proposed guidelines make no mention of the spontaneous and growing protests around the U.S. and Canada by men who are speaking out angrily about having been forced as children to undergo circumcision. “As a public health organization, the CDC should be calling for a study of the true risks and complications from circumcision that occur over the lifetime of boys and men,” says Chapin, “before it promotes its evidence-free claim that the benefits of newborn circumcision outweigh its harms.” The American Academy of Pediatrics released a statement in 2012 promoting the benefits of infant circumcision and calling for insurers and state Medicaid programs to pay for the surgery, performed in the U.S. often without anesthesia. This report is at sharp odds with the ethical and medical stance taken by physicians here and in Europe concerning the removal of healthy sexual tissue from children who cannot consent. In early 2013 in the journal Pediatrics, a large group of physicians, medical organizations, and ethicists from European, Scandinavian, and Commonwealth countries issued <a href="http://pediatrics.aappublications.org/content/early/2013/03/12/peds.2012-2896" rel="noopener" target="_blank">a strongly-worded statement</a>, calling American medicine’s support for infant circumcision “culturally biased,” and “different from [the conclusions] reached by physicians in other parts of the Western world, including Europe, Canada and Australia." In October 2014, Britain’s National Health Service affirmed its previous position stating that, “most healthcare professionals now agree that the risks associated with routine circumcision, such as infection and excessive bleeding, outweigh any potential benefits.” <h2>Centers for Disease Control ignoring the medical evidence</h2> <h3>Statement by Attorneys for the Rights of the Child</h3> The human rights organization <a href="http://www.arclaw.org/" rel="noopener" target="_blank">Attorneys for the Rights of the Child</a> (ARC) is preparing a response to the Centers for Disease Control and Prevention (CDC) regarding its release on December 2, 2014 of a draft of proposed circumcision guidelines. J. Steven Svoboda, ARC’s Executive Director, commented today, “Sadly, the CDC has chosen to ignore the medical evidence to try to justify an outmoded and painful cultural—not medical—practice. In these days of constantly mounting medical costs and ever scarcer resources, we simply cannot afford to continue supporting and performing a harmful and antiquated procedure.” Regarding the CDC’s claim that circumcision’s benefits outweigh the risks, Svoboda commented, “The CDC omitted the functions of the amputated tissue. If the CDC advocates for cutting off a body part, shouldn’t we know what that body part does?” Svoboda commented, “If circumcision is as desirable as the CDC suggests, why are European countries moving towards banning it, why are their males healthier than Americans, and why does the CDC not come out and recommend it?” By the CDC’s own admission, Americans are increasingly choosing to leave their sons intact, as circumcision rates have plunged in recent years. Svoboda added, “A recent study by Bossio et al in the Journal of Sexual Medicine, concluded that the literature favoring circumcision contains considerable gaps, lacks rigor and is largely not applicable to North America.” Studies of HIV in adult males in Africa suffer from methodological and statistical errors and even if valid, given vast differences in health conditions and modes of transmission, the results can hardly be applied to justify infant male circumcision in the United States. “Doctors cannot ethically remove tissue from babies without consent, based on speculation about their possible sexual behavior decades later,” Svoboda added. “Male circumcision,” Svoboda said, “violates a child’s right to bodily integrity, not to mention numerous civil and criminal statutes.” Malpractice awards are mounting up; a list of seventy such cases were released by ARC, the largest amounts to 22.8 million dollars (Antonio Willis v. Northside Hospital Atlanta, March 1991) <h2>Legal and child health experts criticise new circumcision guidelines</h2> Last Tuesday, the Centers for Disease Control and Prevention (CDC) released its proposed guidelines on male circumcision for public comment. The new federal guidelines would recommend male circumcision as a healthy choice that doctors should offer for parents to make for their sons and for teenagers and adults to consider. The CDC background report claims that circumcision has been shown to prevent HIV, HPV and other infections. The new CDC report mimics the 2012 American Academy of Pediatrics Circumcision Policy Statement which drew widespread criticism for its claim that circumcision benefits outweigh the risks. IntactNews asked the CDC for comment about the risks for an average American male in acquiring HIV. “It’s hard to establish one, single figure for risk of HIV acquisition by a heterosexual male,” the CDC responded in an email to IntactNews today, saying the risks are not well documented. <a href="http://www.hivlawandpolicy.org/resources/heterosexual-risk-hiv-1-infection-sexual-act-systematic-review-and-meta-analysis" rel="noopener" target="_blank">One study estimates</a> the chance of an American male acquiring HIV through a single unprotected sex act with a known HIV+ female partner is less than 0.04%. That adds up to a 6% risk per year, with an estimated total of 620 new HIV infections per year for white, heterosexual males with known HIV+ or high-risk female partners. What these numbers show is that the average American man has a comparably low risk of getting HIV through unprotected sex. In fact, the number of average American men getting infected with HIV per year is so low that the CDC does not have data on this demographic. As one legal expert comments, “It is ludicrous and scientifically unsound to recommend the removal of a normal body part from all males to reduce the incidence of sexually transmitted diseases that can be prevented by ABC—practicing abstinence, being faithful and using condoms,” says David Llewellyn, an Atlanta-based attorney whose practice focuses on botched and wrongful circumcisions. “The idea that doctors should counsel teenage boys to get circumcised rather than teaching them ABC is equally absurd. “Furthermore, the CDC recommendations completely ignore the known functions of the foreskin, how circumcision changes the penis, and the hidden but well recognized common injuries that happen every day as a direct result of neonatal circumcision. In my practice, I see the devastating results of circumcision every day. In particular, the high rate of the narrowing of the urinary opening (meatal stenosis) which occurs to tens of thousands of circumcised boys every year. This is not sufficiently addressed by the CDC, even though it is a well-known complication of circumcision. The CDC needs to be paying more than lip service to the devastating effects of these injuries. ” Pediatric urologist warns on high incidence of circumcision complications and other harm “It is regrettable that the CDC has chosen to position itself on the wrong side of scientific evidence with its endorsement of circumcision for male newborns and heterosexual adult males,” says Dr. Alexandre T. Rotta, Chief of Pediatric Critical Care at University Hospitals in Cleveland, Ohio. “By cherry-picking data that, at best, have marginal relevance (if any) in parts of Africa with high heterosexual HIV transmission, the CDC recommendation is empty, counterintuitive, and irrelevant to the health of the very Americans it aims to protect. As a pediatrician, I am deeply troubled by this form of government-endorsed mutilation of children, fragile human beings who will forever be robbed of the right to make an informed decision on such a deeply personal matter carrying irreversible consequences. This is an egregious violation of personal autonomy and medical ethics.” Source: Experts denounce CDC’s “blind promotion” of circumcision in proposed guidelines, <a href="http://intactnews.org/" rel="noopener" target="_blank">Intact News, 4 December 2014</a> Further critical comment at the <a href="http://chhrp.org/index.php/news/chhrp-responds-to-the-cdc/" rel="noopener" target="_blank">Canadian Children's Health and Human Rights Partnership</a> <h2>Centers for Disease circumcision guidelines unethical and medically unsound</h2> The following comment on the draft guidelines for circumcision issued by the United States Centers for Disease Control was released by <a href="http://arclaw.org/" rel="noopener" target="_blank">Attorneys for the Rights of the Child</a> and <a href="http://www.intactamerica.org/" rel="noopener" target="_blank">Intact America</a>. In compiling its proposed recommendations, the CDC has ignored the considerable and reputable literature from the fields of medicine, medical ethics, law, and human rights that calls into question the legitimacy of foreskin removal (circumcision) as a health care measure. Recommendation 1 acknowledges that routine circumcision in the United States, though performed “medically,” is primarily a religious, social, cultural and cosmetic procedure. As such, and in the absence of a diagnosable pathology, the circumcision of infants and children, and the circumcision of any individual in the absence of truly informed consent by physicians who understand the normal male genitalia and the function and benefits of the foreskin, is unethical. The CDC fails to mention that numerous medical organizations, legislatures, physicians and ethicists from European and Commonwealth countries with sophisticated medical systems and lower rates of sexually transmitted infections (STIs), including HIV, have criticized the American medical establishment for its cultural bias toward circumcision, for exaggerating the procedure’s benefits, and for ignoring and understating its risks and harms. The CDC also fails to acknowledge that even the merest pin prick of a minor girl’s genitals – whether motivated by religion, culture or aesthetic preference – violates federal laws against “female genital mutilation.” The United States Constitution guarantees equal treatment of females and males, and thus the circumcision of non-consenting male minors combined with the protection of female minors constitutes illegal discrimination. It also may constitute establishment of a religion in violation of the United States Constitution. Recommendation 2 states that all sexually active adolescent and adult males need to use “other” (i.e., other than circumcision) “proven HIV and STI risk-reduction strategies.” The question must then be asked: Why perform surgery at all, especially considering that no benefit whatsoever is obtained for the (circumcised) male’s sexual partners? Recommendation 3 fails to mention that there has been no systematic longitudinal study of the long-term harms and complications from neonatal circumcision – many of which doctors are not taught to recognize and some of which do not appear until later in life. Nor do the recommendations acknowledge that unnecessary surgery in itself causes harm. As a California Appeals Court has stated, “Even if a surgery is executed flawlessly, if the surgery were unnecessary, the surgery in and of itself constitutes harm. (Tortorella v. Castro, 140 Cal. App.4th 1, 43 Cal. Rptr.3d 853, Cal.App. 2 Dist. (2006)) Recommendation 4 fails to mention: <ul> <li>Urinary tract infections can be treated in boys, as in girls, with simple antibiotics rather than the surgical removal of a normal healthy body part.</li> <li>Balanitis and balanoposthitis are easily treatable with topical creams.</li> <li>Penile cancer is extremely rare, and no medical organization (including the American Cancer Society) recommends circumcision as a preventive measure. The CDC’s reference to a “possibility” that circumcised males are less likely to experience prostate cancer is speculative and unproven and therefore its mention by the CDC as an argument for circumcision is inappropriate.</li> <li>The CDC acknowledges that “the risk [of HIV and STIs] for any individual neonate, child or adolescent cannot be definitively defined at the time that a circumcision decision is made.” The CDC also shockingly fails to examine and weigh the immunological, protective, erogenous, and other functions of the tissue that is to be removed. Unknown risks and omitted harms cannot be meaningfully weighed against asserted benefits.</li> <li>Surrogate (i.e., parental) permission for a procedure on a child is valid only in the case of a serious or life-threatening disease or illness. The American Academy of Pediatrics (AAP) states that the surrogate is limited to providing “informed permission for diagnosis and treatment of children.” (American Academy of Pediatrics Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995;95(2):314–7.) Non-therapeutic child circumcision is neither diagnosis nor treatment and thus falls outside parental power to consent. A normal boy with a normal foreskin should never be a candidate for circumcision surgery.</li> <li>Regarding “the timing of male circumcision,” the recommendations inexplicably dismiss the important fact that infants are not at risk of STIs. The recommendations also mention the lower cost of neonatal circumcision as justification. This claim is irrelevant, as any surgery is too expensive if it is unnecessary.</li> <li>Regarding “complications,” mounting evidence indicates that both circumcised men and their partners experience sexual problems as a result of the male having had his foreskin permanently removed.</li> </ul> The AAP’s 2012 technical report on circumcision has been roundly criticized for reasons also applicable to the CDC recommendations: cultural bias, cherry-picking of evidence, repeatedly stating that benefits of circumcision outweigh its risks without providing evidence of the harms, and omitting information about the functions of the foreskin. In sum, the CDC exaggerates the benefits of circumcision, minimizes its risks, utterly ignores the function and benefits of the foreskin, and blithely disregards critical ethical and legal questions regarding the rights of all children to enjoy their normal, natural sex organs. <h3>US media scent winds of change</h3> Even the mainstream United States media, usually avid in their promotion of circumcision have been forced to recognise that Americans are now “telling Uncle Sam to leave the foreskin alone” Cheryl Wetzstein, <a href="http://www.washingtontimes.com/news/2014/dec/9/cdc-circumsion-proposal-getting-thumbs-down/" rel="noopener" target="_blank">Americians push back against CDC recommendation on circumcision</a>, Washington Times, 9 December 2014 Victoria Colliver, <a href="http://www.sfchronicle.com/health/article/Federal-circumcision-guidelines-meet-with-5944107.php?t=7a6651e708&cmpid=twitter-tablet#/0" rel="noopener" target="_blank">Federal circumcision guidelines meet with opposition</a>, San Francisco Chronicle, 10 December 2014 <h2>Superficial, inadequate and ideological: Child health expert’s scathing review of CDC circumcision guidelines</h2> Unscholarly, selective and biased are a few of the more complimentary terms applied by paediatrician Robert Van Howe to the draft guidelines on male circumcision issued for public comment by the United States Centers for Disease Control in December 2014. Appointed as an official peer reviewer for the guidelines, Dr Van Howe, Professor of Paediatrics at Michigan Central University, did not muck about. In a 200-page review, with over 1300 references, he subjected every statement in the CDC’s draft to a withering critique and found nearly all its facts to be wrong, its claims dubious, its conclusions invalid, and its recommendations dangerous. The most striking features of the document were the glaring gaps in its research, the lack of logic in its arguments, and its irresponsible resort to scare tactics, particularly its attempt to use fear of AIDS in sub-Saharan Africa as a means of driving Americans to embrace circumcision. As Professor Van Howe asks, if the CDC guidelines are meant to assist Americans, how come it is so obsessed with Africa? More specifically, Van Howe identifies seven major flaws in the CDC’s report. (1) It lacks scientific rigour. (2) It is thin on details. (3) It disregards much of the medical evidence. (4) It ignores the anatomy, physiology and functions of the foreskin. (5) It is out of step with world opinion on non-therapeutic circumcision. (6) Despite massive consultation, the document is not significantly different from the draft issued in 2007 – eight years ago. (7) It urges health providers to supply the public with misleading, irrelevant and out of date information. The introductory paragraphs of Professor Van Howe’s peer review are given below. The full document may be <a href="https://cmich.academia.edu/RobertVanHowe" rel="noopener" target="_blank">seen at his Academia.edu page.</a> A CDC-requested, Evidence-based Critique of the Centers for Disease Control and Prevention 2014 Draft on Male Circumcision: How Ideology and Selective Science Lead to Superficial, Culturally-biased Recommendations by the CDC Several things are remarkable about this draft. First, is the obvious lack of scientific and scholarly rigor that went into preparing this draft. While it is stated that the writers of the draft performed a search of the medical literature, the evidence (in the form of the draft itself) indicates that their search was far from complete. Instead of collecting and analyzing data, they relied on review articles to do the work for them. One review article was published in 1983 — a bit dated to say the least. In some sections, the draft relied on opinion pieces as their sources of information. In areas where review articles were not available, the information provided was far from complete. For example, in reviewing the medical literature on the impact of male circumcision in North America, which is a major thrust of the draft, only two of the eight available studies are mentioned. Similarly, no serious attempt was made to review the harms, risks, complications, or pain associated with circumcision. The draft has only 255 references, some of which are redundant, which are only a small sampling of the material available in the literature. A PUBMED search using the search word “circumcision” on January 12, 2015 identified 6338 publications. The draft also ignores basic epidemiological principles. It fails to apply the standards that are needed to identify when an intervention should be applied. Throughout the draft, it is assumed that circumcision will be successful as a primary prevention for HIV, when the data clearly demonstrate that it is ineffective as primary prevention. Even its role as a secondary preventive measure has only been evaluated in one study in the United States, which included a very small, limited population. For this very small population, modeling by the CDC has estimated that circumcision’s impact on infection risk is nearly inconsequential. Policy should be based on more than one small subset of patients from a single study when several other studies fail to support this conclusion. It is clear that both the investigators of the randomized clinical trials and the CDC draft authors do not understand the epidemiological difference between efficacy (a positive finding in a research setting) and effectiveness (positive results in the real world). The draft fails to adequately scrutinize the validity of the few studies it identified. It assumed the randomized clinical trials could not harbor any bias (the draft actually states this!) and did not question the methodology of these studies, although their methodology has been questioned extensively. Instead of accepting the study results at face value, the expectation of scholarly rigor would demand that these studies be carefully scrutinized, and a determination made as to whether the studies generated valid results and/or if the criticisms raised about these studies were convincing. The writers of the draft made no effort to question or analyze these studies. If a student were to submit these drafts for consideration as a senior undergraduate or master’s thesis, they would fail based on their lack of scholarship. It appears the CDC was only going through the motions in preparing this draft. If the CDC had performed an adequate search of the medical literature and applied the expected level of scholarly rigor, their conclusions and recommendations would have been different. Perhaps that was the point. Perhaps the hope was, by releasing the draft with a selective bibliography, no one would recognize the lack of scholarly effort or call the CDC out on doing a subpar job. It worked for the American Academy of Pediatrics, and they seemed to get away with it. The difference is that CDC documents are open for public comment because it is a government agency. One would think that, after all of the embarrassment the CDC has endured in the recent past, they would want to put their best foot forward by publishing a rigorous, balanced, evidence-based assessment of male circumcision. That obviously did not happen. Second, is the lack of attention to detail. Many of the citations given have the authors and journals incorrectly listed. Several of the citations require updating, while several of the citations were redundant. There are several misspellings in the manuscript. This indicates the CDC did not expend sufficient effort putting forth this piece of work, which is consistent with its lack of scholarly rigor. Third, is the wanton disregard for the medical evidence. It is clear throughout that the writers of the CDC draft believe absolutely in the presumption that infant male circumcision can reduce HIV and sexually transmitted infections beyond a shadow of a doubt. As a consequence, the draft goes about finding evidence to support their presumption and primarily presents evidence supportive of this presumption, despite evidence to the contrary. The quality of the evidence supporting the presumption is never questioned. Any evidence that does not support their presumption is either ignored, criticized, or dismissed. As a consequence, the draft is laughably biased and reflects the expectation bias of its writers. Fourth, is the lack of a thorough discussion of the foreskin and its anatomy, histology, physiology, and function. It is standard procedure for review articles of this type to review these topics to provide a basic science foundation. How can the CDC discuss the biological plausibility of sexually transmitted infections without a knowledge of the basic anatomy, histology, physiology, and function? This information must be included since health care providers must understand what is lost by removing the normal foreskin/prepuce. How else can they explain the impact of its removal to patients? This information is also an essential element of the disclosure given during the informed consent process. Fifth, is how out of step the CDC is with the rest of the world. National medical organizations and human rights groups throughout the world, including the Council of Europe, are, in increasing numbers, denouncing infant circumcision as being medically unnecessary and a blatant human rights violation. At this point in time, the CDC and the American Academy of Pediatrics are the last stronghold in the defense of infant circumcision. Remarkably, the draft fails to mention all the medical organizations outside of the United States who have weighed in with an opposing opinion on male circumcision. Is there some source of special knowledge the CDC has in its possession that allowed them to reach conclusions that are diametrically opposed to every other national medical organization (other than the American Academy of Pediatrics)? If it exists, why is it missing from the draft? Please provide enlightenment. If the CDC has a clue, they could at least share it. Sixth, it took over seven years for the CDC to produce a substandard, scientifically unacceptable product, nearly identical in content to what was presented at the 2007 consultation. Finally, the most remarkable thing is that the CDC is recommending clinicians and health care providers relay information that is counterfactual, incomplete, and biased to medical decision makers. In essence, they are deliberately encouraging health care providers to misinform their patients and thus commit medical malpractice. The CDC needs to throw out this draft and start again from scratch, this time without a preconceived conclusion in mind. They need to review the entire medical literature, thoroughly scrutinize the studies in the literature, and properly apply basic epidemiological principles. When they have done so, they need to consult with experts from around the world to make sure their findings are not culturally biased. They also need to focus on the United States, not Africa. Source: Robert Van Howe, MD, MS, FAAP. A CDC-requested, Evidence-based Critique of the Centers for Disease Control and Prevention 2014 Draft on Male Circumcision: How Ideology and Selective Science Lead to Superficial, Culturally-biased Recommendations by the CDC. January 2015. <a href="https://www.academia.edu/10553782" rel="noopener" target="_blank">Full text available at Academia.edu</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Centers for Disease Control and male circumcision: Americans out of touch and living in the past darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> A survey of recent medical literature on circumcision has concluded that many of the studies are of poor quality, are not sufficiently evidence-based, lack methodological rigour, and are often not applicable to developed countries. The paper, by J.A. Bossio and colleagues, concludes that more research is needed, particularly on the impact of circumcision on sexual experience and other harms and risks arising from the surgery. Parts of the abstract read as follows: Introduction. Male circumcision is one of the most commonly performed surgical procedures worldwide and a subject that has been the center of considerable debate. Recently, the American Academy of Pediatrics released a statement affirming that the medical benefits of neonatal circumcision outweigh the risks. At present, however, the majority of the literature on circumcision is based on research that is not necessarily applicable to North American populations, as it fails to take into account factors likely to influence the interpretability and applicability of the results. Results. This review highlights considerable gaps within the current literature on circumcision. The emphasis is on factors that should be addressed in order to influence research in becoming more applicable to North American populations. Such gaps include a need for rigorous, empirically based methodologies to address questions about circumcision and sexual functioning, penile sensitivity, the effect of circumcision on men’s sexual partners, and reasons for circumcision. Additional factors that should be addressed in future research include the effects of age at circumcision (with an emphasis on neonatal circumcision) and the need for objective research outcomes. Conclusion. Further research is needed to inform policy makers, health-care professionals, and stakeholders (parents and individuals invested in this debate) with regard to the decision to perform routine circumcision on male neonates in North America. CIA comment: For all it moderation of language, this paper, by three impartial observers, is a pretty devastating indictment of claims that the “benefits” of circumcision outweigh the risks. As the authors of the study point out, most of the research cited to back up this assertion was conducted in poverty-stricken Third World countries with poorly developed health services and high levels of sexually transmitted disease, especially HIV-AIDS. The results of this research is simply not applicable to developed countries such as north America, Canada and Australia. Just as serious is the study’s conclusion that much of the pro-circumcision literature is not based on sufficient evidence or conducted with sufficient methodological rigours to justify the sort of conclusions that the <a href="https://www.circinfo.org/United_States_circumcision_policy.html">American Academy of Pediatrics</a> came up with in 2012. As the authors of the survey point out, a great deal more research is needed before any firm conclusions about the balance of benefits, risks and harms can be reached. Source: Bossio JA, Pukall CF, and Steele S. <a href="http://onlinelibrary.wiley.com/doi/10.1111/jsm.12703/abstract" rel="noopener" target="_blank">A review of the current state of the male circumcision literature</a>. Journal of Sexual Medicine, Online first, 6 October 2014. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Circumcision literature full of gaps, lacks rigour and relevance ( darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> An article in the Libertarian magazine The Objective Standard takes a hard look at American circumcision practices and finds them an unacceptable violation of the autonomy and rights of the individual, no different from female genital mutilation and. This the second libertarian critique of circumcision, following on from an <a href="https://www.circinfo.org/news_2014.html#testa">earlier paper by Testa and Block</a>, which argued that circumcision violated a person’s natural right to self-ownership. It is a significant development, as libertarianism is a large and growing movement in the United States, and you would expect that defence of the integrity of the individual body would be their Number 1 principle. We are not sure how comfortably the call to ban circumcision (presumably by government legislation and sanctions) sits with their libertarian principles, but it could be justified on the basis that governments have a legitimate role in preventing persons from harming others, as John Stuart Mill allowed. The author’s conclusion follows: Female genital mutilation is a horrifying, barbaric, and evil practice. The routine circumcision of infant boys in the United States is in principle and in practice no different. Far from a legitimate medical procedure conceived of to treat or prevent an actual illness, infant male circumcision emerged in the United States in the late 19th century as a blatant resurrection of Jewish circumcision in its most barbaric form. Although there may be in certain circumstances legitimate medical reasons for a teenage or adult male to consent to some form of circumcision, the choice should be his to make. Neither his parents nor his doctors have a moral right to rob him of that choice by mutilating him in infancy. It is time for all Americans — circumcised and not circumcised — to see the practice of routine infant circumcision for what it is: a barbaric, uncivilized, rights-violating ritual that should be prohibited by law. Of course, the fact that most American men were circumcised in infancy, and the fact that their parents approved of the procedure, may make many people feel awkward about taking a public stand against neonatal circumcision. A similar obstacle stands in the way of outlawing female genital mutilation in other parts of the world. Yet the fact remains that the practice is barbaric and immoral — even if most parents innocently erred in approving the procedure for their children based on the unprofessional and frankly cowardly advice of their physicians. Until Americans are willing to admit that many of them and many of their parents made a mistake, the practice of male genital mutilation in the United States is unlikely to end. Parents should arm themselves with the facts and proudly refuse to circumcise their sons, just as they would refuse to mutilate their daughters. And physicians should end their nonsensical and immoral deference to barbaric cultural and religious practices, stop promoting the quack science used to rationalize the practice, properly educate parents about circumcision, and righteously refuse to perform routine infant circumcisions. Genital mutilation is wrong. It is as wrong for boys as it is for girls. And everyone who cares about the rights of American boys must take a stand against it. Source: Joseph England. <a href="https://www.theobjectivestandard.com/issues/2015-spring/circumcision-in-america" rel="noopener" target="_blank">Circumcision in America</a>. The Objective Standard 10 (1), February 2015. <h3>Links to other sources</h3> Science journalist Matthew Tontonoz wonders <a href="http://matthewtontonoz.com/2015/01/05/why-is-circumcision-so-popular-in-america/" rel="noopener" target="_blank">why the United States is so obsessed with circumcision</a> American doctor and medical ethicist <a href="http://www.hhrjournal.org/2009/08/31/promoting-infant-male-circumcision-to-reduce-transmission-of-hiv-a-flawed-policy-for-the-us" rel="noopener" target="_blank">explains why promoting circumcision of infants is not the right way to combat HIV-AIDS</a> Science journalist Spoony Quine <a href="http://madsciencewriter.blogspot.com.au/2013/05/the-foreskin-why-is-it-such-secret-in.htm" rel="noopener" target="_blank">wonders why the foreskin is such a secret in North America</a> <a id="mgmfgm" name="mgmfgm"></a>Parallels between female genital mutilation and male circumcision recognised A recent series of articles in the quality magazine The Atlantic shows that American are waking up to the fact that there are more similarities and differences between female genital mutilation and male circumcision - or female and male genital cutting, as they would be called if we were using gender-neutral language. This is an astounding development. Ten or even five years ago it would have been all but inconceivable that a mainstream, middlebrow American magazine would run a discussion comparing male and female genital cutting, and even less likely that so many of the comments would have been in favour of their equivalence or at least their comparability. The comments do reveal a surprising level of US insularity and unawareness of what happens (or does not happen) in the rest of the developed world, but at the same time provide proof that a critical attitude to non-therapeutic circumcision of boys is no longer confined to an eccentric fringe. The survey of readers’ opinions concludes with a comment from leading bioethics analyst Brian Earp: Because every group that practices female genital alteration also practices male genital alteration (but not vice versa), usually under similar conditions and for similar reasons, the two forms of cutting are, as the anthropologist Zachary Androus notes, closely linked in the practitioner's minds. Therefore many scholars think that it will be impossible to get rid of FGM without also addressing male circumcision at the same time, since to eliminate exactly one half of a community's initiation rites is perplexing to those who see the customs as mirror images of each other. (<a href="http://blog.practicalethics.ox.ac.uk/2014/02/female-genital-mutilation-and-male-circumcision-time-to-confront-the-double-standard" rel="noopener" target="_blank">I go into that last point in greater detail here</a>.) The upshot is that, even from a purely strategic perspective, there is good reason to think that treating this as a child's rights issue (where the undeniable power imbalance can be discerned, i.e., between adults and children) rather than as a sex-based issue (because the diversity of these practices and their close affiliation in the minds of practitioners makes that a fundamentally problematic approach) will be more successful in the long run in eliminating both. <a href="http://www.theatlantic.com/health/archive/2015/05/male-circumcision-vs-female-circumcision/392732/" rel="noopener" target="_blank">How Similar is Female Genital Mutilation to Male Circumcision? Your Thoughts</a>. Atlantic Magazine, 13 May 2015. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Libertarian rejects circumcision darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>Why do we need a circumcision policy at all?</h2> Statement by Statement Analysis of the 2012 Report from the American Academy of Pediatrics Task Force on Circumcision: When National Organizations are Guided by Personal Agendas II by Robert S. Van Howe, MD, MS, FAAP Professor and Interim Chair of Pediatrics Central Michigan University College of Medicine <h3>Abstract</h3> In September of 2012, the American Academy of Pediatrics Task Force on Circumcision released its report, which concluded that the benefits of the procedure outweighed the risks. A close analysis of the report reveals the Task Force used a selective, subjective and biased bibliography to support their predetermined conclusions. The Task Force neglected to discuss the anatomy, function, and normal development of the foreskin, nor did they discuss the harm or ethical consequences associated with circumcision. The Task Force deviated from standard practices in its analysis of the medical literature thereby producing a report that falls far below the quality standards set by other AAP policy statements. The report promoted expansion of the procedure as well as the revenue streams for those who perform it. Since release of the report, other national medical organizations have rejected infant circumcision as unwarranted medically and as ethically unacceptable. No organizations outside of the United States have adopted their conclusions. The report is poorly written, poorly researched, makes unsubstantiated claims, and reaches an illogical conclusion. Introduction In the weeks following the release of the report from the American Academy of Pediatrics (AAP) Task Force on Circumcision in September of 2012, I went through the report statement and compiled my critique of their statement. I shared this critique with a handful of people at that time. In December 2014, the Centers for Disease Control and Prevention (CDC) subjected their “draft recommendation” to public comment. As a peer-reviewer selected by the CDC, I wrote and submitted a detailed commentary, which can be found at Academia.edu. Given the effort I had previously put into providing a critique of the AAP’s 2012 report, it is time to update my analysis of the AAP’s misguided statement and distribute it more widely. <h3>General Themes</h3> 1. Recommendations are predetermined and supported by a selective bibliography. 2. There is a failure to adequately research the topics and medical evidence. 3. There is a failure to assign the appropriate weight to the evidence with a tendency to give more weight to evidence that supports circumcision and less weight to evidence that does not support circumcision, even between studies of similar design. 4. There is a failure to evaluate the quality of individual publications using standard methods. 5. There is a failure to recognize or discuss the value and function of the foreskin. 6. There is a failure to recognize the value and human rights of the infant. 7. Conclusions are reached despite no evidence to support them. 8. The report is more reflective of the make-up of the committee rather than medical evidence. 9. A key element of this report is to assure that parents can continue to request infant male circumcision, so that physicians can continue to be paid for performing this procedure. 10. Consistent disdain is expressed toward males who have an intact penis: the term “uncircumcised” is pejorative, inflammatory, and a form of bias consistent with hate speech. 11. There is an underlying racist/anti-immigrant theme. 12. Pieces of information are extracted from citations and used to support their agenda, but other pieces of information from the same citation that do not support their agenda are ignored. 13. There is a failure to acknowledge studies that do not support the benefits of circumcision. 14. The work of scientists who question the validity of the medical benefits of circumcision is routinely attacked. 15. The report was two years out of date at the time it was released. <h3>Issues not properly addressed:</h3> 1. Human rights and bioethics, including the right to an open future. 2. The most common complication of circumcision, meatal stenosis, as well as the myriad of other complications. 3. The anatomy of the normal, complete, intact penis. 4. The histology, anatomy, and function of the foreskin. 5. The psychological sequelae of circumcision. 6. The harms and risks associated with circumcision. 7. Cost utility analysis. 8. Contrary evidence and opinions. 9. Incidence of phimosis and balanitis in intact boys. 10. Non-specific urethritis and the overall risk of sexually transmitted infections. 11. The impact of risk compensation. 12. Positions taken by other national medical organizations throughout the world. ABSTRACT Statement 1: “Male circumcision consists of the surgical removal of some, or all, of the foreskin (or prepuce) from the penis.” Comment: Accurate, but incomplete, and below academic standards. It does not adequately describe the foreskin as functional, erogenous tissue. The Task Force fails to mention the anatomy, histology, physiology, or sexual functions of the foreskin. This is unacceptable since most medical reviews and discussions begin with a complete scientific discussion of the basic anatomy, histology, and physiology in regards to the organ, or disease, being discussed before moving on to other topics of pathophysiology, disease, epidemiology, and treatment. In the 1984 AAP pamphlet “Care of the Uncircumcised Penis” the functions of the foreskin are discussed. In subsequent versions of the same pamphlet dropped the discussion of the subsequent versions of the same pamphlet dropped the discussion of the functions of the foreskin as though they never existed. When contacted, officials from the AAP are unable identify why this information was removed from the pamphlet. <a href="http://www.circumcision.org/pamphlet.htm" rel="noopener" target="_blank">Old pamphlet available here</a> <a href="https://www.academia.edu/23431341/Statement_by_Statement_Analysis_of_the_2012_Report_from_the_American_Academy_of_Pediatrics_Task_Force_on_Circumcision_When_National_Organizations_are_Guided_by_Personal_Agendas_II" rel="noopener" target="_blank">Professor Van Howe's Academia page</a> <h2>Do we really need a policy on circumcision?</h2> The weaknesses and biases of the AAP policy are bad enough, but a more fundamental question is why and whether we need a policy on circumcision in the first place. No other AAP policy document focuses so obsessively on a particular procedure or on a particular element of a bodily organ – for make no mistake, any circumcision policy is really a report card on the foreskin itself. We don’t see policy statements on the liver, the nose or the heart, but rather on the diseases and other problems that affect those organs; we don’t find suspicious and hostile criticisms of those organs, but advice on how to manage such problems with a view to protecting and preserving them. The AAP has policies on sinusitis, the management of liver cancer and heart disease – and a policy on the foreskin, as though it was some sort of cancerous growth or disease that needed to be “dealt with”. Clearly, something very strange is going on here. The odd thing is that the original purpose of circumcision policy statements issued by paediatric bodies in the early 1970s was to stop circumcision. Routine circumcision had become entrenched in Anglophone medical practice during the first half of the twentieth century, but by the 1960s paediatricians (child health specialists) had become aware that the operation was causing much harm and not doing any obvious good. The harms were not merely a high incidence of complications, but a flood of damaged penises, so scarred and distorted that one Australian doctor reported that he was “appalled at the phallic mutilations exhibited by many of these children, some of whom have even been subjected to a subsequent “tidying up” procedure after being badly mauled in infancy” (A. Clements, Medical Journal of Australia, 29 April 1972, 946). Circumcision policy statements issued by paediatric bodies in Australia, Canada and the United States were intended to halt this butchery by reassuring parents and doctors that the foreskin was not pathogenic or any kind of problem, but a normal element of the male genitals that could safely be left to its own devices. These statements had a substantial impact in Australia, where circumcision incidence plummeted from more than 80% in the 1950s to less than 12% by the mid-1990s. There was a moderate decline in Canada, but only a slight fall in the USA, where incidence actually rose after the AAP’s first policy statement in 1971. It did not begin to decline until the mid-1980s, and even then only after agitation by community-based anti-circumcision groups. Why is the United States different? One of the reasons for this exceptionalism is that in the USA routine circumcision is not the province of paediatricians (who are left with the sad job of repairing the botches), but of obstetricians and gynecologists. They had taken over the operation in the 1930s, assisted by the invention of the Gomco circumcision clamp by obstetrician Hiram Yellen, and had incorporated it as a routine step in the childbirth process – a procedure no more optional or problematic than tying off the umbilical cord. As Miller and Snyder wrote rapturously in 1953, “the obstetrician finishes his episiotomy, walks across the hall and circumcises the infant, and is finished with the whole business. The time saved for both the physician and nursing staff is considerable”; even better, “no babies are forgotten and left uncircumcised.” For reasons of professional pride, emotional commitment and financial advantage, the obgyns have not been keen to give the practice up. Another reason was pressure from religious minorities, worried that if circumcision generally was abandoned it would become difficult to maintain traditional circumcision practices within their own communities. (Translated: if Jewish boys saw that other boys their age had their foreskin, they would want one too.) The fear became more intense after the passage of the United Nations Convention on the Rights of the Child in 1989, with its threatening provision in Article 24 (3): “States Parties shall take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children”. Even worse, this was followed by the passage of legislation in many countries to prohibit and criminalise any form of female genital cutting. Jewish and Muslim religious leaders were afraid that such legislation would lead to demands that similar protection be given to boys – a fear that has proved well-founded. In response to this threat, the conservatives took advantage of the obvious loophole in the CRC – the reference to “prejudicial to health”. If it could be shown that circumcision was not prejudicial to health (i.e. harmful) or, even better, that it was beneficial, the situation would be saved: genital cutting of girls could be banned as harmful (and condemned as FGM), while circumcision of boys was preserved, and even promoted as a boost to male reproductive health. The most masterly exponent of this strategy was Edgar Schoen, an MD employed by Kaiser Health (a leading supplier of circumcision equipment and services), a fervent believer in circumcision, and a prolific contributor to medical journals, among whose editors he had many friends. His presence on the AAP taskforce that produced the 1989 policy statement ensured that the document adopted a more positive stance towards circumcision, asserting that it had definite health advantages, while not going so far as to recommend it. The tone of the policy was, however, more hostile than previously towards the foreskin, tending to picture it as a source of disease and a difficult problem for parents. Skin wars The battle intensified during the 1990s, as the grass-roots anti-circumcision forces grew more confident, and the conservative believers in circumcision scratched around for additional medical benefits. Urinary tract infections were suddenly found to be more common in uncircumcised boys, and the arrival of HIV-AIDS offered hope that a foreskin-HIV link could be found if the researchers were given enough money and worked hard enough. The AAP’s 1999 policy statement was less pro-circumcision, reflecting the waning influence of Schoen (by then retired), and the rising importance of bioethical and human rights issues, the growing presence of the anti-circumcision movement, and an increasing body of circumcision-critical material in the professional literature. It was this Cold War stand-off that probably accounted for the long delay in the production of the next statement, not finalised and released until 2012. By then there had been two contradictory developments. On the anti-circumcision front, both the Royal Dutch Medical Association and the Royal Australasian College of Physicians released statements critical of circumcision. The Dutch policy was stronger, finding nothing positive to say about circumcision, and forcefully rejecting it as medically harmful and ethically impermissible. The RACP was more cautious, but nonetheless agreed with Dutch concerns about bioethical and human rights issues, and concluded that routine circumcision was not warranted and should not be recommended. On the pro-circumcision front, the researchers finally managed to find evidence that circumcision of adults in some regions of sub-Saharan Africa could reduce the risk of female to male transmission of HIV during unprotected intercourse, a discovery that rapidly led to the funding of massive circumcision programs in the epidemic areas. The discovery and programs were not short of publicity, especially not after a naïve geek called Bill Gates was persuaded to provide a few hundred million dollars from his charitable foundation. (Though some cynics wondered whether Microsoft was really quite the most appropriate source for an anti-virus program.) Out of Africa The question then became whether the African revelations were relevant to infants and boys in developed countries, where HIV was not a heterosexual epidemic but a relatively rare disease largely confined to homosexual men and injecting drug users. Considering that the African Random Clinical Trial results were released in 2007 and the policies of the Dutch and the RACP in 2010, it is evident that Dutch and Australian health authorities judged the answer to be NO, and this attitude was soon shared by health authorities in other developed countries, with one exception: yes, the United States (as usual). A series of softening-up articles on the benefits of circumcision published in the Journal of the American Medical Association and other forums prepared the way for the AAP’s 2012 statement. This claimed that the results of the African RCTs, and a few related studies, constituted enough “new evidence” to justify a more positive stance towards circumcision: while the AAP could not go so far as to actually recommend it, the Task Force asserted that “the benefits exceeded the risks”, and left the impression (by insinuation and omission, rather than by explicit statement) that any parent who failed to take the hint and get his boys circumcised was really pretty irresponsible. AAP strategy backfires It did not take long for the flaws and gaps in the policy’s reasoning and evidence to attract numerous critiques, a reaction that rather surprised (and hurt) the Task Force, which seems to have thought that the authority of the AAP (as a powerful American institution) would crush opposition in the Unites States and impress medical organisations in other countries. On the contrary, as Professor Van Howe points out in his latest critique, the most striking result of the AAP’s efforts has been to reanimate the anti-circumcision forces: “One of the unintended consequences of the release of the 2012 Report of the AAP Task Force on Circumcision is that it helped rally European physicians, ethicists, and legal scholars to protest the human rights abuses associated with the practice. In the wake of the report’s release, the Council of Europe and a number of national medical organizations in a variety of European countries have condemned the practice of newborn circumcision as a human rights violation. They have found the “benefits” of circumcision to be inconsequential. When responding to a letter written by 38 leading European medical experts that characterized the Task Force as “culturally biased,” instead of addressing the substantive issues raised, the Task Force responded with righteous indignation and issued a thinly-veiled accusation that the writers were anti-Semitic. … “The irony is that their reactionary approach backfired. When the Task Force led the charge to preserve infant circumcision, they were hoping to attract the attention of Americans and bring the Europeans, who had to that point remained silent on the issue, in line behind them. Instead, it woke up the sensibilities of the Europeans, which has now been noticed by many Americans, leading them to question the practice of infant circumcision in increasing numbers. By overreacting and putting out a statement based on cultural beliefs and personal preference rather than on science, the Task Force members have embarrassed themselves, the members of the American Academy of Pediatrics, and American physicians generally. What is interesting is the pro-circumcision physicians who have infiltrated the Centers for Disease Control and Prevention tried the same tactic in late 2014 by issuing a “draft recommendation,” which took seven years to develop, was short on science and execution, and it was based primarily on cultural factors. Unlike the Task Force report, a public commentary period was required for their “draft recommendations.” Of the thousands of comments submitted, over 95% exposed the scholarly dishonesty of their draft.” And not only European physicians: papers published by Australian child health experts have tacitly rejected the AAP position, and the cruelest blow was delivered by the Canadians: far from endorsing or following the US position, as was widely expected, the updated policy of the Canadian Paediatric Society maintained its recommendation against routine circumcision. Et tu, Brute? Now that the AAP is completely isolated in its (admittedly equivocal) support for circumcision, the question is how long the 2012 policy can survive. If its flaws are as great as Professor Van Howe contends, our conclusion must be that it should never have been issued, and that the AAP ought to get to work on a new one as soon as they can muster a competent team. Why have a policy on circumcision at all? But why have a policy on circumcision in the first place – remembering that it is really a policy on the foreskin: should it be allowed to survive, or should it be condemned as a menace to society (as Dr Peter Charles Remondino insisted in the 1890s)? Health authorities do not prepare policies on other bodily organs – liver, spleen, scrotum, breast etc – but rather on how to manage disorders that affect them. The only comparable policies are those condemning any form of female genital cutting, but these do not single out the clitoris, labia or female prepuce as objects of suspicion. What makes the genitals so special? Could it be, as Professor Van Howe suggests, their cultural, religious and social significance, rather than their role in the physiology and anatomy of the body, that makes the difference? Had circumcision not been introduced by anti-sex doctors in the nineteenth century it would not, of course, be necessary to have a policy on circumcision at all. Countries outside the Anglophone world, where circumcision did not become established, have never felt the need for a such a policy – at least, not until the increasing Muslim presence and the recent provocation from the AAP made them wonder. But in the Anglophone world doctors did introduce circumcision, and it is only right and proper that they should take responsibility for putting a stop to it. If we take Jonathan Hutchinson’s claim about the value of circumcision as a preventive of masturbation and syphilis, aired in the mid-1850s, as the starting-point of circumcision advocacy, we can see that it took about a century of medical propaganda for circumcision to become routine and ubiquitous, reaching its zenith of popularity in the 1950s and 60s. With that example in mind, we may reasonably infer that it will take another century for the practice to die out, along with the Old Guard generation that believes in it. If we take Douglas Gairdner’s celebrated paper of 1949 as the beginning of the end, we may reasonably expect circumcision to have been pretty much eradicated by the middle of this century. That may seem like the distant future, but there are only 34 years separating us from 2050, almost exactly a single generation. It took well over 100 years to abolish slavery, and I think we can be confident that we will be able to eliminate circumcision without the need for a civil war. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Critique of the AAP circumcision policy raises larger question darby