 The second bravest person who ever lived was the first person to try a raw oyster. The bravest person was the first one to consent to being circumcised. Today some people routinely eat oysters and up to 30% of the world's male population have a part of their penis removed shortly after birth. The statistics for Americans are around 70% or as high as 80% among European Americans and the rates vary with religion and region. By contrast, the European rates are much lower, less than 20%, less than 1% in places like Finland and in Muslim controlled Central Asia and the Middle East, the rates are nearly 100%. The faiths of Islam, Christianity and Judaism practice circumcision as a religious right and obligation of faith and some African tribes practice adult circumcision as part of the rights of manhood. The earliest record of circumcision comes from ancient Egyptian art and the Semitic peoples appear to have adopted the practice long before the writing of scriptures suggesting that widespread circumcision predated the Bible by thousands of years. Alexander the Great, a Greek Macedonian who was raised in a non-circumcision culture was said to have radically altered the traditional circumcision practice of the peoples he conquered. What an odd thing for diverse cultures to adopt. I suppose certain early cultures might have associated foreskin with poor hygienic practices. In some cultures circumcision of young boys was probably a sort of coming out party for the generals, a test of manhood as well. Some tribal cultures consider the phallus to be a symbol of fertility or power, the act of modifying it has an effect on the perception of the person. That cultural interest probably became codified in cults and religious ceremonies like ceremonial tattooing or ear piercing or many other body modifications practiced by world cultures. The genitals have always been a religious obsession up to and including full self-castration by male priests of Sibley. So although we associate circumcision with certain religious groups, the practice seems to predate the religion, and the cultural practice was co-opted by priests rather than invented by them. I had no idea that male circumcision was such a touchy subject. Growing up as I did in the American Midwest, circumcision was a normal part of labor and delivery. When my wife and I were discussing our plans with our obstetrician, we really hadn't discussed the topic together. In the end we made a hasty decision to carry on the tradition in my family, circumcision. Now that I look back, I regret basing such an important medical decision on such casual thinking or lack thereof. However, I don't think the issue is as clear cut, pun intended, as it might appear at first glance. I want to throw out a few issues that I've been thinking about. I hope you'll watch the full video, tell me your thoughts on the topic, and hopefully start some useful discussion. My mind is far from made up on this topic, and I confess the more I learn, the more complex are the issues and the harder it's been to take a strong stand on either side. Sometimes knowledge is the enemy of confidence, and vice versa. 1. Modern infant circumcision methods are relatively safe and minimize suffering, but are not risk-free nor painless. Most circumcisions are done in one of three methods, the Plastibel, Gomko, or Mogan clamps. All of them are relatively very safe with few recorded complications, but there are complications and risks. Not the least of which is the risk of cosmetic or functional damage to the penis, minor or serious infection, and bleeding or hemorrhage. These risks are usually lowest in newborns. Older children and adults who undergo the surgery are much more likely to have serious complications. There have been numerous studies that attempted to quantify adverse events. If we simply include any symptom, including redness or bleeding, the rates range from 2 to 40% depending on definitions. If the study only includes serious complications, which would be issues requiring further medical care, the rates are usually around 0.2%. That's two out of a thousand circumcisions where the procedure required additional medical care. Usually these were a matter of bringing the baby back into the doctor, or it could include an ER visit. I couldn't find any recorded cases of death in my survey of the medical literature, but I did find an estimate of one death for every 500,000 circumcisions, suggested by an opponent of circumcision, Lowell King, in a 1975 report. I suspect that's a bit high, and includes cases where the proximal cause may not have actually been the circumcision. Nevertheless, there are risks up to and including death, although they are very rare. Two, there are some medical benefits to routine infant circumcision. In some cases, removal of the foreskin is medically necessary to prevent more serious pathology. We could call that medical circumcision, but I'm talking here specifically about circumcision of boys as a routine practice. We can break the topics of benefits into three categories. STD transmission risk, UTI risk and severity, and avoidance of rare conditions. Particularly, the HIV risk argument must be addressed. Foreskin is a favorite target of HIV infection. It is loaded with the kind of cells most easily infected, the Langerhans cells, but not protected by a resistant layer of protein called keratin. We would predict, therefore, that circumcised men without a foreskin would be less likely to be infected. The process should also affect the ability to transmit the virus, as microscopic openings in the foreskin allow the virus an easy exit to the next host. That's the mechanism or theory behind protective circumcision. How does that translate into actual protection? Well, the evidence seems pretty strongly in favor, although there are some who disagree. In high-risk populations like those in East and Southern Africa, it's very protective. We're talking about 60% or more reductions in transmission. That could save millions of lives, and the public health agencies that operate in the area, like the World Health Organization, are actively investigating if the benefits outweigh the risks, and if circumcision clinics for adults are practical. If we had an effective alternative for preventing the spread of HIV, if condom use and testing were more prevalent, I would say that this argument could be neutralized. However, at the present moment, circumcision is very effective in these high-risk populations. In lower-risk populations, the HIV risk reduction is much more modest. The protection doesn't just benefit men, it also benefits women, and protective effects are only detectable in heterosexual transmission. By benefiting women, it can also prevent newborn children from being born infected, and that saves the lives of little baby boys. Similar effects and similar mechanisms have been identified for several other STDs. General ulcers, herpes, trichomoniasis, and human papillomavirus infection transmission are all reduced in circumcised individuals. Historia and gonorrhea transmission, on the other hand, don't appear to be affected. The papillomavirus infection is especially important as HPVs are associated with various cancers, most especially of the cervix, where it's implicated in nearly 100% of cases. Worldwide, cervical cancer is estimated to affect 490,000 women and cause 270,000 deaths annually. Circumcised men are both less likely to be infected and also less likely to transmit the infection. This may help to save the lives of women. Vaccines against HPV may change the cost-to-benefit equation, but for the moment, I think this is a point in favour of circumcision. Circumcision also reduces the risk of penile cancer, although the prevalence of this condition is so rare that it's hard to put much emphasis on this benefit. Circumcision reduces the likelihood of a urinary tract infection by eliminating an area where infections can form and remain hidden. Since newborns have a non-retractable foreskin, it provides a little pocket where bacteria can lodge and grow. As a result, keeping a circumcised penis clean and dry appears to be easier, but this could probably be overcome by a little extra effort on the part of the parents. What kind of magnitude of benefit is seen in circumcised infant boys? 1% of newborn boys develop a UTI, urinary tract infection, and the risk reduction is about 10-fold. That sounds pretty impressive, but it means that we have to circumcise about 110 boys to prevent one UTI from occurring, which probably doesn't quite overcome the risk of complications from the procedure. On the other hand, some little boys have a very high risk of UTI due to medical conditions where urine flows back into the ureter and kidney, and circumcision lowers their risk enormously. In these cases, benefits clearly outweigh risks, and only four circumcisions are needed to prevent one UTI. If you've ever had a urinary tract infection, you know they're not fun and can potentially become quite severe. Lastly, male infant circumcision can be protective against certain rare conditions. Femosis is a good example where the foreskin doesn't become retractable. This is a serious medical condition, and can require therapeutic circumcision, or it can sometimes be treated with a simple steroid cream. There are other such conditions of the foreskin that can be prevented by its removal at a very young age, although the cost-to-benefit ratio for these may be questionable. 3. Routine circumcisions are not recommended by most medical authorities. I'm just going to read the position statement of the American Academy of Pediatrics. It typifies the fairly generic statements that neither condone nor condemn the cultural practice of circumcision, but don't endorse a purely medical indication for infant circumcision. The American Academy of Pediatrics believes that circumcision has potential medical benefits and advantages as well as risks. The existing scientific evidence is not sufficient to recommend routine circumcision. Therefore, because the procedure is not essential to a child's current well-being, we recommend that the decision to circumcise is one best made by parents in consultation with their pediatrician, taking into account what is in the best interests of the child, including medical, religious, cultural, and ethnic traditions. This is the current position statement, and it reflects the modern consensus. In the past, the AAP has taken stronger stands against or in favor of circumcision, depending on current evidence in the political environment. Circumcision has seen a decline in recent years in the U.S., and I think the medical community themselves are responsible for the change, advising parents about both medical and ethical concerns of circumcision. Four, the evidence about the negative health consequences of circumcision is a mixed bag. One odd thing about being a biologist is that so much is known about the human body that we have to specialize in one particular topic. In this case, as I read through the list of adverse events associated with male circumcision, I was painfully reminded of how little I know about that area of the body, despite extensive personal study and examination in my youth. Male infant circumcision may have some serious associated risks, but it has to be remembered that one in three men are circumcised and that the practice goes back into the misty recesses of prehistory, so the effects must be fairly rare or non-critical. However, the kinds of complications listed in the literature require that I go back to a medical dictionary. Here are some of the terms I encountered. Lymphedema, urinary fistula, hypospedias, epispedias, metisulceration, and gland-skin bridges. Catastrophic events like partial or total loss of the function of the penis occur once in every million or so circumcisions done under modern surgical conditions. One primary concern is a loss of sexual pleasure. The tip of the penis is exposed, and over time the skin might be more likely to become keratinized or tougher and thicker, and therefore a little less sensitive, although most studies didn't find this to be the case. There is also some concern about mutual enjoyment of intercourse, although I didn't find much evidence for this in the literature either. In fact, in some studies the opposite is true, with surveys of female partners in Africa, stating that they preferred sex with their partner after he was circumcised. There are also some who speculate that the pain and suffering of the procedure, together with inadequate anesthesia, has an effect on the child that translates into psychological damage. There is a definite effect on older children between two and six who are old enough to be aware, but too young to understand, called castration anxiety. All of this represents the purely scientific, purely medical pros and cons. This ignores the most deeply controversial topic, the ethics and morality of surgical removal of a natural part of the human body. Here, science is silent. Is it right for a parent to make such a decision for a child, one that is permanent and profound, painful and risky? Does the physician honor their oath to do no harm if they perform this procedure without a medical indication? I've thought a very long time on this topic, and I think that my own decision for my son might not have been justified. I deeply regret that all this consideration comes now when the decision is long past. I don't think he was permanently harmed, and I don't think he'll have any problems in the future, but I wish I'd given the topic more thought at the time. I am most swayed by the argument about the rights of the infant to make choices about their own body. I would prefer if the child could make this decision. Unfortunately, the risk of complications of adult circumcision make it much higher risk compared to infant circumcision. If the child can't make the decision at the point where the procedure is safest, I think the parent usually has the best interest of the child at heart, and any decision that they make is part of their legal guardianship. It's not an optimal solution, but it's one we've practiced in other cases where important medical or legal decisions need to be made for a child. I strongly support the use of anesthetic during the procedure, something that is not routinely done in the U.S. Some figures suggest only about 25% of circumcisions are done under anesthesia. Maybe I don't understand the case against, but it seems like preventing pain and suffering is the least we can do for the baby boy. Lastly, I know the topic of female genital cutting is bound to come up in discussion. I don't consider the two procedures to be equal. The closest analog in women to the male foreskin is the clitoral hood. This is rarely the only tissue removed. Usually the clitoris is either partially or entirely removed. This is the equivalent of castration in males, something not practiced in modern cultures. I'd like to keep the two issues separated, but I think it's only fair to allow for comparisons so long as a proper equivalence is made. I am strongly opposed to female genital cutting. I'd like to summarize my own impressions from research on this topic. I think the medical evidence is slightly in favor of routine circumcision. There are no benefits that cannot be obtained in other ways. The most effective way to prevent HIV and other STD transmission is still condom use or abstinence. Condom use is the best solution. Proper foreskin hygiene, likewise, can greatly reduce UTI rates in young boys without the need for surgical prevention. In the very real world, circumcision is an imperfect solution, but one that seems to work. It could potentially save millions of lives in high-risk areas. The medical benefits are offset by medical risks and possible psychological or sexual effects later in life, but I still think the evidence is slightly in favor. On the other hand, the ethical issues around circumcision are, on the balance, anti-circumcision. It seems a violation of the rights of the child to an intact body, and it seems to violate core medical ethics to do no harm. There is also the religious, cultural, or family tradition to consider. Parents could be argued to have certain rights to decide what traditions their children follow until the age of maturity. This is not an argument that I find very compelling, so I won't go any deeper into it. I look forward to a robust discussion on the topic. Before you start writing your 500-character argument, though, I would make three requests. 1. Try to avoid overly emotional wording and tactics. 2. If you make an assertion of fact, a proper citation to a source is much appreciated. Note that links are not only not allowed in YouTube comments, but they aren't even proper citations. 3. And this is the challenge. I would ask that you avoid using any terms that you'd be uncomfortable reading aloud to a nice old lady you met on the bus. Good luck and be creative. Extravagantly fictional prizes will be awarded to the best use of creatively non-offensive language. I have so many papers to cite that I've had trouble posting them below. Instead, I've posted a link to the citations in the underbar. As always, thanks for watching.