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Circumcision

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Update: Due to the vociferous and emotive nature of many comments, I am not publishing over half submitted on this post. Just so you know your chances…

One thing that I have read repeatedly is that circumcision rates in the United States have fallen over the past generation. For non-Americans in the readership, yes, American males are customarily circumcised even if they are not from a religious or cultural tradition where this is the norm (i.e., they are not Muslim, Jewish, or East or West African). For Americans, yes, circumcision has nothing to do with Christianity (something that would be obvious if more Americans actually read the New Testament, instead of just quoting selective passages from it). But looking more closely at the data it seems that the decline in circumcision is predominantly a function of its collapse as a normative practice in the western states!


One might think that this is due to demographic changes in the West, as Hispanics have lower rates of circumcision than non-Hispanics (black or white). But while California had circumcision rates of 22% in 2009, Washington state’s was 15%. It seems that Medicaid coverage has a strong effect, but this can’t explain all of the variation. In the late 1970s the western states had the same circumcision rates as the northeastern states. Today northeastern states have circumcision rates two to three times higher than in the west. And it doesn’t map onto politics either. Extremely conservative (and western) Utah has circumcision rates of 42%. Blue Rhode Island has rates of 76%.

Finally, I want to observe here that the males who were born during the era of diverging circumcision rates are now entering sexual maturity en masse. This is going to shape the expectations of both sexes, and perhaps result in some surprises for those who relocate to the other coast as they transition to adulthood….

(Republished from Discover/GNXP by permission of author or representative)
 
• Category: Science • Tags: Circumcision, Culture, Health 
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The New York Times has a piece on an update to the American Academy of Pediatrics position statement on circumcision (shifting toward a more pro-circumcision position of neutrality). In the United States the rates of circumcision for infant boys has gone from 80-90% to ~50% (there are regional variations, so only a minority of boys in the Pacific Northwest are circumcised). A few years ago Jesse Bering put up a post, Is male circumcision a humanitarian act?, where he actually wrote “Nobody knows where your child will live as an adult (perhaps Africa), or how rampant HIV will be there….” I like taking probabilities into account, but this is ridiculous.

Let’s ignore Jewish ritual circumcision, which has to be done in early infancy from what I know. The vast majority of the world’s circumcised men live in Africa and the Muslim world, with a substantial minority in the USA and American-influenced cultures.* So you don’t need to focus on infant circumcision at all. In Turkey circumcision is performed on boys who are considerably older. I understand that an 11 year old boy is not an adult, but if sexually transmitted diseases are your primary concern, then why not diminish some of the ethical concerns (granted, you will not abolish them) with surgery upon infants by pushing back the timeline? You could even push the age to 18 and still gain a lot of your preventive bang-for-the-buck in the United States. A substantial minority of 18 year old adults are virgins, and most of those who have had sex have not had many partners. In Africa free adult circumcisions have been reputedly popular in some areas, so I don’t see the problem if adults are offered this procedure for free.**

* South Korea and Philippines both have widespread circumcision due to American influence. Interestingly, a large number of Americans think that circumcision is a religious mandate for Christians. I’ve had Catholic friends explain it exactly this way, making it quite clear that the stereotype about Catholics not reading the Bible has a lot of validity.

** For the record, I do accept that in Africa male circumcision has some preventative value (there are also cross-country comparisons in Southeast Asia). But it seems like a totally irrelevant issue in most of the developed world. There’s no difference in the AIDS epidemic in South Korea vs. Japan, because both are advanced developing countries, and a society-wide heterosexual AIDS epidemic seems to never materialize in such nations.

(Republished from Discover/GNXP by permission of author or representative)
 
• Category: Science • Tags: Circumcision, Health, Public Health 
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When Michelle mentioned on Twitter that she was going to write about circumcision, I told her to expect some angry people to come out of the wood-work. Today she has a post up at Scientific American, What’s the deal with male circumcision and female cervical cancer? She concludes:

In addition, while it is true that women with circumcised partners are less likely to get cervical cancer, they are not immune. Women with circumcised partners still contract HPV and develop cervical cancer! They just do it at a reduced rate.

There are other methods that are much more likely to reduce a woman’s chance of contracting HPV and developing cervical cancer, such as vaccination and condom use. Therefore, from a public health standpoint in the United States, it may not be necessary to circumcise male babies solely for the purpose of reducing the risk of cervical cancer in his future sexual partners (of course, this doesn’t take into account the possibility that the child might not be heterosexual).

On the whole I think that Michelle’s take is reasonable and fair-minded. But, I think numbers are of the essence here. What is the expected reduction in rate of risk? This was the major bone I had to pick with Jesse Bering’s post on this topic last year at Scientific American. Bering closes on a pro-circumcision note on public health grounds:

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.

If I’m not being generous, I’d have to say that circumcising your son because he might live in Africa which might still have a rampant HIV epidemic 20-30 years from now, is kind of a stupid decision if grounded on probabilistic logic. After all the probabilities of the various outcomes contingent upon your priors matter. My future children will be raised in the United States of America. If male, they will likely be straight. They will probably middle to upper-middle-class. HIV rates vary a great deal by demographic category. I know I won’t allow my sons to be circumcised as infants. I don’t see the need, and I am familiar with the literature on the efficacy of mass circumcision in preventing the spread of sexually transmitted diseases in some environments.

But, if I lived in South Africa I might make a different decision based on the probabilities of my different environment. This is why I would dissent a bit from Michelle’s note that even women with circumcised partners can develop cervical cancer. Risk assessment, by its nature, should not be viewed dichotomously. To make proper decisions based on probabilities you need to take into account the magnitudes of all the risks.

(Republished from Discover/GNXP by permission of author or representative)
 
• Category: Science • Tags: Circumcision, Health, Medicine 
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Razib Khan
About Razib Khan

"I have degrees in biology and biochemistry, a passion for genetics, history, and philosophy, and shrimp is my favorite food. If you want to know more, see the links at http://www.razib.com"