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Bering in Mind

Bering in Mind

A research psychologist's curious look at human behavior

Is male circumcision a humanitarian act?

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So there’s this fellow—an inquisitive sort, even if not particularly bright—whom one day is asked by his ogress of a wife to drive to the store to buy a ham. Obediently, he does so, finds an impressive specimen of meat at the store, returns home and, grinning widely, places it proudly on the kitchen table before the woman. “You idiot!” screams the boorish wife. “Why didn’t you have the butcher cut off the end?” Now, our man might be dim-witted, but he’s not without a certain practical mindedness. So he asks his wife, meekly, why the end must be cut off. “Ach,” she grumbles, heaving the ham onto the counter where she begins fussily carving off the end. “Such a stupid question. That’s just the way it’s done. Mother did it and her mother before her and her mother before her.” There’s a rather puzzling hesitation in his wife’s answer that intrigues the man, however. So, still perplexed, he phones his mother-in-law—who apparently is as pleasant as his wife is unpleasant—and asks the old lady why she cuts off the ends of her hams. “You know,” says the woman, “I once posed this very question to my own grandmother. And do you know what she told me? Her old baking tray was so small that she had to cut off the end of the ham to fit it inside!” 

There are many different versions of this parable of the severed ham, but the moral of the story is this: many of today’s rituals—even sacred ones held by uncompromisingly stern authority figures—are just empty repetitions of a utilitarian past. In considering male circumcision, this tale of a needlessly removed hunk of ham doesn’t require a terribly huge stretch of our imaginations to apply. The surgical removing of foreskin from a neonate’s penis is seen by many critics as an outdated, cruel and unnecessary procedure that—although it may once have had some practical purpose in times past—is now done primarily out of blind habit and unquestioning obedience to “because I said so” authority figures. Although male circumcision is rare in Europe except for Jewish and Islamic subpopulations for which the procedure is a core part of religious group identity, about 70 percent of U.S. males—regardless of their religion—are circumcised. It’s embarrassing to admit, but growing up in Middle America, I didn’t even know what a nonmutilated penis looked like until the advent of the Internet. (Then again, I was also 14 before I realized that condoms weren’t, in fact, what old people in Florida lived in.) According to a 2003 report, the only meaningful predictor of whether parents will opt to get their infant son circumcised is whether the father’s own penis is circumcised—there’s a positive correlation, in case you’re wondering. Cut off the end of the ham—er, penis—because that’s what my daddy did and his daddy before him. 

But much as I may want to join the cause to save the prepuces, the anti-circumcision stance may not be as humanitarian as it appears. Objection on the grounds that male circumcision is a somewhat bizarre, bloody and frightening ritual was probably very reasonable throughout much of modern history. But this ancient practice, which dates back at least to the Neolithic period, just happens to have important health implications today that are completely unrelated to the hollow rituals of our forebears’ foreskin removal. This strange procedure of lopping off the ends of penises may well have persevered over the eons on the shakiest grounds of justification, grounds that invoked religious, cultural or aesthetic reasons. But, ironically, it may now finally be playing a serious—even heroic—role in staving off a much more crippling problem:

Mounting evidence shows that male circumcision dramatically reduces the risk of HIV infection, at least for heterosexual males.

According to researchers writing in a 2009 issue of AIDS Patient Care and STDs, the prophylactic effect of male circumcision is owed to the following physical facts:

 

There are high densities of HIV target cells in the inner mucosal surface of the human foreskin … These HIV target cells lie beneath a protective layer of keratin, which is absent on the inner surface of the prepuce. By removing all or part of the foreskin, circumcision reduces both the number and susceptibility of target cells to HIV infection.

 

Since 2007, several randomized clinical trials have established that male circumcision could lower the risk of HIV acquisition in heterosexual men by as much as 62 percent. Sixty-two percent! So far, these studies have been limited to African populations that have been particularly hard-hit by AIDS-related casualties. In South Africa, a third of reproductive-aged women are infected. If you’re a 15-year-old living in that country today, there’s a 59 percent chance that you’ll die before reaching your 60th birthday; just 10 years ago, these odds were only 29 percent.

Here’s how the clinical trials basically worked. Thousands of adult, HIV-negative, sexually active, uncircumcised men in Kenya, Uganda and South Africa agreed to be randomly assigned to a circumcision group or a no-circumcision group. Those randomly assigned to the circumcision group had their foreskins removed by medical professionals, were told to abstain from intercourse until their wounds healed (about three weeks—there may actually be a greater risk of HIV infection during this period, so this is vital), and then were instructed to return to the clinic at six-month intervals to test for the virus. The results were unequivocal: two years later, the circumcised males were significantly less likely than their uncircumcised peers to have contracted HIV. In fact, the researchers decided to end these clinical trials early for ethical reasons: with data so clearly showing the advantages of circumcision in an environment rife with the virus, it’s hard to justify a further wait-and-see approach for those men that had been randomly assigned to the no-circumcision group.

For the Ugandan study, 22 of 2,387 circumcised men acquired HIV over the two-year period compared to 45 of 2,430 uncircumcised men who were infected during this time span. Extensive interview methods confirmed that the two groups did not differ in terms of their actual sexual behaviors, enabling the authors to conclude that the results were owed directly to the circumcision intervention. (For those data heads among you, P < 0.00001.) These numbers may not sound massive, but note that they refer to only a 24-month period; over a lifetime, they would become dramatic.

In fact, using the results from the South African study, one group of computer modellers crunched these numbers to find out how many lives mass neonatal male circumcision could potentially save in this region over a 10-year period. They concluded that male circumcision could save the lives of 300,000 people in Southern Africa alone. Move forward 20 years, they pointed out, and 2 to 7 million deaths could be averted.

It’s presently unknown whether homosexual males would also benefit from circumcision. The studies simply haven’t been done. But Beijing STD specialist Yuhua Ruan and colleagues suspect that circumcision would protect insertive partners (“tops”) against HIV much more than it would receptive partners (“bottoms”). This is because the anal mucosa is highly susceptible to trauma and so the risk of HIV infection through receptive anal sex is very high. The lesser benefit served by being on the receiving end might also apply to heterosexual couples, however. A study published in The Lancet last year found that circumcision in HIV-infected men from Uganda appeared to offer no protection against the virus to their female partners. Thus, although it’s too soon to tell, the real benefits of circumcision may be reserved primarily for heterosexual men or insertive gay men. But that’s still a lot of people whose foreskins may be compromising their health.

In a 2007 report in The Lancet, UCLA infectious disease specialist Sharif Sawires and his colleagues put it bluntly:

 

In regions where high HIV prevalence exposes the population to risks that have a devastating effect on entire societies, the risks associated with male circumcision could be outweighed by the potential lives saved …

 

 

We encourage multicultural, bilateral, and government agencies, along with non-governmental organizations to make this life-saving strategy affordable and safely available to relevant populations bearing the heaviest burden.

 

These authors certainly aren’t alone in endorsing male circumcision on HIV-preventative grounds. It is now being recommended as a crucial, relatively simple tool against the threat of AIDS by the World Health Organization and UNAIDS. Importantly, of course, these experts also hastily point out that circumcision is just one effective strategy and must be used in conjunction with other preventative measures such as condoms and education.

But prescribing routine male circumcision on HIV-preventative grounds has been met with controversy. Other leading health organizations have refused to take a position. For example, the Royal Australian College of Physicians and the American Academy of Pediatrics neither advocate nor denounce the procedure. As Israeli medical researchers Margherita Brusa and Michael Barlain discuss at length in their excellent review article last year in an issue of Bioethics, in some societies, “medicalizing” male circumcision intrudes on important religious and cultural rituals associated with the practice. In Jewish communities, of course, mohalim—expert circumcisers—are religious figures practicing an art that is passed down through generations, and removing the child’s foreskin is a deeply symbolic affair. In fact, it’s during the circumcision ceremony that boys are given their personal Hebrew names. (Just call me Yishai.) Tribal circumcision of young adolescents in many African nations is an important rite of passage into adulthood—another deeply engrained, essential tradition.

There is also the issue of what Brusa and Barlain refer to as the “naturalism&rdqurdquo; argument against male circumcision, which is that it is inherently wrong to alter the natural human body, particularly the bodies of infants and children who cannot give their informed consent to such an invasive procedure. On the face of it, this is an appealing position. Arguments such as “the prepuce is not a birth defect” alongside emotionally loaded images of screaming babies or graphic depictions of botched circumcisions certainly tug at our heartstrings and make us upset. But persuasive on logical grounds? Not exactly. Ultimately, the authors reject the naturalism argument. Cutting our children’s hair is “unnatural” too, much like punching holes in their earlobes and straightening their teeth through painful orthodontic procedures. Yet, as far as I’m aware, there are no societies fighting to end the travesty of these heinous crimes against nature. Similarly, arguments insinuating that foreskins would have been eliminated by natural selection if they were disadvantageous are deeply flawed. Biological evolution cannot anticipate viral arms races of the future.

You’d even struggle to get everyone on the same page about what the “natural”’ penis actually is. For Jews, the Talmud describes the foreskin as an unnecessary pathological tissue, and leaving it intact is akin to leaving the umbilical cord dangling. By contrast, the ancient Greeks and Romans saw the prepuce more as a tuft of hair or a piece of cloth; without it, the man was naked because—under typical, uncircumcised conditions—the sight of the glans penis meant sexual arousal.

What about the issue of “bodily integrity”? What gives parents the right to decide for their helpless sons? I think there’s probably more currency in this line of reasoning than in the naturalism argument. Why should we deliberately inflict harm on people under the guise of preventative therapy against a disease that they may or may not be at risk for later in life, or they might not benefit from the procedure as much as other men would? After all, who knows: your little boy might grow up to be the receptive partner in a gay relationship, or perhaps an asexual or even a monogamous zoophile in love with his horse. But do you really want to bet on those odds?

Like any surgical procedure, male circumcision isn’t without risk of unpleasant complications. In this case, haemorrhage, sepsis, fistula, meatal stenosis, removal of excessive skin and even penile loss can occur. But in medical settings, these complications are extraordinarily rare, appearing in just a fraction of cases, and male circumcision remains the most common surgical procedure practiced in the world. Of course, you might opt to give your child the luxury of choice, waiting for him to make his own informed decision about whether circumcision makes sense for him. But, if you’re anything like me, that’s one thing you’re very glad to have gotten under your belt the first week of your life. For all I know, I’ve had a phantom foreskin ever since; no pain, though, just a lot of pleasure. 

I started this piece with an open mind but I’ll close by putting my cards clearly on the table. For me, if one fully appreciates the scientific findings reported by these landmark studies with sub-Saharan African men, circumcision is the more humane decision. Some minor bloodletting today could spare that child unthinkable degrees of suffering tomorrow. Nobody knows where your child will live as an adult (perhaps Africa), or how rampant HIV will be there, or whether he’ll wear a condom every time he has sex with a stranger, or whether an infected, beautiful woman will cross his path on the day he forgets to tuck a condom into his wallet. Admittedly, my own “son” is a border terrier, but this issue is still a no-brainer to me. However, I’m well aware that male circumcision is a contentious topic for many people, some of whom, aghast, will make their opinions known to me in the coming days.

But here’s a final counterpoint to anti-circumcision you may not have considered. Last year, I reported research by evolutionary psychologist Gordon Gallup suggesting that, owing to the increased exposure of the coronal ridge, circumcised penises may very well be more effective at withdrawing competitors’ sperm from the vaginal tracts of promiscuous females than uncircumcised penises. Having your infant son’s foreskin removed could reduce your boy’s chances of being cuckolded later on by his adulterous future wife. Now that’s thinking ahead.

 

In this column presented by Scientific American Mind magazine, research psychologist Jesse Bering of Queen's University Belfast ponders some of the more obscure aspects of everyday human behavior. Ever wonder why yawning is contagious, why we point with our index fingers instead of our thumbs or whether being breastfed as an infant influences your sexual preferences as an adult? Get a closer look at the latest data as “Bering in Mind” tackles these and other quirky questions about human nature. Sign up for the RSS feed or friend Dr. Bering on Facebook and never miss an installment again. For articles published prior to September 29, 2009, click here: older Bering in Mind columns.

Image ©iStockphoto.com/stuartpitkin

The views expressed are those of the author and are not necessarily those of Scientific American.

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