The ethics of circumcision

Andrew Gross

March 12, 2023

INTRODUCTION

In November 2022 Brian Earp's paper, The Ethics of Circumcision, was published as a chapter in a book on bioethics. [1] A bioethicist and research fellow at the University of Oxford in England, Earp has described the chapter as "my most up-to-date and comprehensive accounting of the ethics of circumcision." [2] This is a very well thought-out paper that deserves serious consideration. In this article I provide an analysis and response.

I will begin with a brief summary of the 32-page chapter. I will cite more than 30 statements that are false or otherwise problematic. I will respond to Earp's primary assertions in support of his position, particularly his assertion that a patient's informed consent is required and is generally sufficient - in order for a beneficial but medically unnecessary procedure to be ethical. I will explain how a medical advancement may change the ethical equation by making foreskin restoration possible. I will demonstrate how Earp's ethical approach to circumcision conflicts with his approaches to gender affirming care and abortion - two related ethical topics that involve gender, genital surgery, bodily autonomy, consent, and the rights of pre-adult humans. Finally, I will conclude with an explanation of why Earp's position is unsustainable, and I will argue that he is not entirely honest in expressing his agenda.

First, I encourage visitors to read The Ethics of Circumcision by Brian D. Earp at the following link:

https://www.researchgate.net/publication/360554804_The_Ethics_of_Circumcision

The Rowman & Littlefield Handbook of Bioethics is available for purchase here.

SUMMARY

Earp begins by separating world cultures into three patterns regarding genital cutting. He declares that he will argue in favor of the culture where both circumcision and FGM are not generally practiced. He states that absent medical need, "it is always morally impermissible for an adult to touch [or] cut" a child's genitals. He rejects any consideration of medical benefits for an elective procedure that lacks a patient's consent. He argues that the only person whose opinion on the value of foreskin should matter is the patient - not parents nor doctors. Earp concludes that routine newborn circumcision in the United States "constitutes an extraordinary moral wrong" carried out on a "sex-discriminatory basis."

MISSTATEMENTS

Unlike most intactivists, Brian Earp is a serious scholar who writes in an analytic manner. He typically presents a compelling argument using high-quality evidence while tending to avoid emotional rhetoric and logical fallacies. He accurately presents and responds to arguments from circumcision promoters and defenders. He even anticipates objections to his arguments.

At first glance it would seem that Earp has made a solid case that circumcising minor boys is unethical. Upon scrutiny, however, one finds several flaws.

The chapter contains several statements that are false, misleading, missing context, or otherwise dubious. For instance: Earp misleadingly asserts that the "foreskin or prepuce... exists in all primates, including humans of both sexes..." [3] He recklessly compares the foreskin to the eyelid. [4] He falsely claims that the foreskin protects against contaminants. [5] He exaggerates the size of foreskin. [6] He falsely describes the foreskin as "the most sensitive part of the penis to warmth." [7] He refers to a static type of sensitivity that doesn't apply to typical sexual activities. [8] His evidence that most uncircumcised males highly value their foreskin is weak. [9] He compares the perpetuation of circumcision to Chinese foot binding. [10] He falsely claims that the AAP argued that banning FGM is discriminatory. [11] He refers to a paper by 38 mostly European physicians (whom he labels "international medical experts") critical of the 2012 AAP policy statement - without mentioning the AAP task force's response. [12][13] He selectively quotes a Canadian Paediatric Society policy statement but ignores the part where the CPS supports parental choice. [14] He cites a Danish Medical Association statement that was not evidence-based, and he ignores the reality that half of all boys begin sexual activity before adulthood. [15][16]

Earp uses an immaterial objection to dismiss certain HIV studies. [17] He falsely claims that a trial found that circumcision increases the risk of HIV transmission. [18] He cites older studies to show that circumcision may put women at greater risk of HIV while ignoring more recent studies that show the opposite. [19] He inappropriately labels the loss of foreskin "a risk of circumcision." [20] He states that adult men always have the option of circumcision, ignoring barriers to surgery. [21] He ignores the fact that penile cancer poses a greater threat to the glans than the procedure that virtually prevents penile cancer. [22] He compares circumcision to earlobe removal. [23] He dishonestly cherry-picks results from different studies in order to claim that complication rates are similar for infants and adults. [24] In asserting that it's extraordinarily difficult to predict a boy's future attitude toward his circumcision, he ignores evidence to the contrary. [25] His assertion that a pediatric genital exam is "morally impermissible," "morally troubling," and "presumptively inappropriate" is contrary to standard pediatric care. [26]

Earp says that "males who speak out [against circumcision] are often ridiculed, derided, and dismissed." Yet he flippantly dismisses circumcised men who speak out in defense of circumcision, suggesting that they don't value foreskin simply because they lack one. This assumption is reminiscent of The Fox and the Grapes, one of Aesop's fables. In the story a fox sees a bunch of juicy grapes hanging from a vine along a high tree branch. No matter how hard he tries, the fox cannot jump high enough to reach the grapes. Frustrated, he tells himself that the grapes were sour and not worth the effort. [27] Earp implies that happily circumcised men display a similar state of cognitive dissonance. "Perhaps this is one reason why [men] circumcised in infancy come to believe the foreskin is 'just a bit of worthless skin.' It helps maintain the subjective disvalue they place on having a foreskin, which is a state they cannot physically be in." Earp cites his own 2018 study in which he found that a man's false beliefs indicated greater satisfaction with being circumcised or dissatisfaction with being uncircumcised. [28] Working independently, British researcher Stephen Moreton and I both found that the test Earp developed to measure circumcision knowledge was slanted and highly subjective. Seven of the ten statements used to test circumcision knowledge were ambiguous, capricious, irrelevant, oversimplified, or otherwise problematic. [29][30] And cognitive dissonance can't explain away the positive views of uncircumcised men who choose circumcision for themselves or their sons or grandsons. [31]-[33]

ETHICS OF CHILDHOOD CIRCUMCISION

Earp's position is that boys who are too young to consent should never be circumcised except in cases of medical necessity. Earp presents his argument "both as a matter of ethics and gender equality." With respect to circumcision Earp refers not only to "babies that have been categorized as male at birth (typically due to the presence of a readily identifiable penis)" - but also to "transgender girls and women... who are affected by penile circumcision." Yet this statement conflicts with his conclusion, in which he asserts that circumcision "happens on an explicitly - that is legally enshrined - sex discriminatory basis." If penile circumcision affects both boys and girls, then by definition it cannot be sex discrimination.

Regardless of how one categorizes transgender individuals, penile circumcision does not constitute sex discrimination. This is a critical point that circumcision opponents don't seem to understand. Boys aren't circumcised because they are boys. Boys are circumcised because they have a penis. The basis for the surgical procedure is the organ - not the patient's biological sex, assigned gender, or gender identity. Circumcision benefits a patient because the penis contains the opening through which contaminants can enter the urinary tract. By contrast, cutting female genitals won't reduce urinary infections; it might actually increase the risk of infection. [34]

Nevertheless Earp says that medical benefits have no bearing on the ethical question. Certified Family Nurse Practitioner Melanie Lindwall Schaab disagrees. "Medical ethics are determined primarily by whether a procedure is medically beneficial. Medically speaking, studies are needed to know whether a preventative medical procedure like circumcision is ethical. In just about every other area of medicine, if research shows it's not medically beneficial, then the discussion of whether it's ethical begins." [35]

THE DECISION MAKER

One ethical problem, Earp maintains, is that the person making the decision is different from the boy who will be affected by the decision. He says that one can't predict whether a boy will grow up to embrace his parents' religious beliefs or cultural traditions, or whether he will disassociate from those beliefs or traditions. Earp argues that the patient is the only person with the moral right to weigh the benefits and risks of an elective procedure. Only a boy should be allowed to make the decision - when he is capable of understanding the effects of the procedure.

Earp distinguishes between a situation in which a boy is not circumcised, and then it turns out that he "would have consented to, and even benefited from, the [circumcision]," and a situation in which a boy is circumcised and then it turns out that he "would not have consented to [circumcision] had he been able to do so." Earp argues that in the first case, in most situations the potential harm is "relatively small"; whereas in the second case, the potential harms - "for example, a feeling of having been sexually violated, or of having had one's most important boundaries not respected - are enormous."

But medical benefits are morally relevant for vaccinations and blood tests, both of which violate a baby's bodily autonomy. In the former case, a foreign substance is forcibly injected into the patient's body. In the latter case, his own blood is forcibly seized from him. Both procedures are performed without the patient's consent, and neither can be justified without medical benefits. Earp distinguishes between circumcision and vaccination in part by appealing to a consensus of medical professionals. "The [medically beneficial] standard may well be appropriate for certain interventions into the body, where... there is very little disagreement among qualified experts as to what those definitions and measurements [of benefits and harms] imply; for example certain childhood vaccinations." He rejects the medical benefits of circumcision because doctors have not reached agreement on weighing benefits and risks. "No committee or panel of medical experts can decide the [ratio of benefits to harms] for everyone else."

Only 3 countries place the varicella (chickenpox) vaccine on their childhood vaccination schedules. Shaab noted that if Earp's criterion for a medical procedure is widespread medical consensus, then by his logic forcibly injecting the chickenpox vaccine on nonconsenting children is unethical. [36]

I maintain that the lack of consensus is precisely why parental choice is appropriate. From both a legal and an ethical perspective, society presumes that a parent acts in her child's best interests. Furthermore, I would argue that parents are affected by the circumcision decision. Parents are the ones who comfort their child if he suffers from urinary tract infections. Parents must live with the agony of seeing their son in pain from the infection and from any side effects of antibiotics. An ethicist may never have to face the effects of a child's foreskin-caused suffering.

Schaab has noted that since parents make decisions about a child's diet, vaccinations, and other health options, to define bodily autonomy as a "child’s right to make permanent decisions about his body" is too broad. She cited Dr. Joseph Mazor, who argued that a more accurate standard for decisions about a child’s body is that they should be made for the child's benefit, not for the benefit of others. [37] Schaab concluded that "because newborn circumcision is generally performed for the child’s (alleged) benefit and is never (or at most, rarely) performed solely for the parents’ benefit, newborn circumcision does not violate the child’s right to bodily integrity." [38]

The British authors of a 2019 book on ethics observed, "If there is a serious clash between the interests of the child and of the parents, we should favour the child. Along these lines, the UN convention on the rights of the child states that 'In all actions concerning children…the best interests of the child shall be a primary consideration.' They added, however, that "if there is a situation where the benefits and burdens are closely balanced, and it isn’t clear which way the scales are leaning – the interests and wishes of parents may tip the balance." [39] That is precisely the case with circumcision.

RELIGIOUS BENEFITS

Comparing circumcision to female infibulation, Earp assigns no weight to religious or cultural benefits because "any bodily harm inflicted on a child, no matter how physically injurious, can in principle be justified by a 'best interests' analysis if the social benefits of the injury - or social costs of keeping one's body intact - are sufficiently great. If you add potential metaphysical benefits or costs, such as might be associated with being perceived to follow or violate the will of a divine entity, the possibility that even a severe bodily injury could be in the overall 'best interests' of a child (including their spiritual interests, to put that way) is increased." Here Earp begs the question by presuming that circumcision is physically harmful. I agree with him that neither religion nor culture can justify inflicting actual harm on a child. But the issue is whether or not circumcision is harmful.

Earp may argue that circumcision is inherently injurious because it involves cutting into the body. By that reasoning any surgical procedure constitutes an injury. Earp later distinguishes between a procedure that is medically necessary and one that is unnecessary. A medically necessary procedure involves a benefit that greatly outweighs any possible harm. Earp weighs the benefits to harm and concludes (correctly) that a medically necessary procedure would be ethical because presumably a patient would consent to the operation. He concludes that circumcision is unethical because consent is uncertain.

Earp dismisses "a parent's personal judgment of the child's best interests" based on religious requirements or cultural traditions because one is unable to ascertain a child's future beliefs and religion could be used to justify any harmful practice. In the first place, circumcision almost certainly wouldn't prevent a boy from joining a different religion or none at all. [40] For the second objection, Earp presumes that circumcision is harmful and then equates circumcision with infibulation, which causes lifelong harm by its very nature.

Earp places no value on a religious motive, nor on the probability that a boy will want to be circumcised. His view is that parents of a hundred boys shouldn't be allowed to provide medical, religious, and cultural benefits of circumcision based on the possibility that even one boy might later object to the procedure.

I disagree. The odds are far greater that a boy raised in a religion or culture where infant circumcision is prevalent will want to have been circumcised in infancy than that he will not want to have been circumcised. A circumcised man in a society where circumcision is seen as normal is extremely likely to be happy or unconcerned about his penile status. Author Westley Smith agrees that "[b]arring circumcision would more stifle a Jewish boy's autonomy rights by depriving him of an essential part of becoming part of the Jewish community. The only choice for the boy wanting to be fully included into Judaism would be to do it in adulthood, when the surgery would be far more complicated and risky." [41]

Rhys Southan, a student of philosophy at the University of Oxford, also agrees. He writes, "If harm is in large part subjective – and to credibly amplify the voices of a tiny minority who regret circumcision, intactivists need to admit it is – cutting is bad only for the people who find it so. It’s dishonest to claim that the joy the Jewish practice of brit milah brings its practitioners counts for nothing when most people who are circumcised for religious reasons do not grow up to think of themselves as abused. The organisation Friends of Refugees of Eastern Europe (FREE), based in New York, says that it has circumcised more than 13,000 Jewish adults who were prohibited from infant circumcision in the Soviet Union. Many of them no doubt felt harmed by not having been circumcised in their infancy. Until far more Jews and Muslims step forward to protest their own circumcisions, to me it looks more hurtful to ban religious circumcision than to leave it alone." [42]

Dr. Allan J. Jacobs, a gynecological oncologist and bioethical expert, noted that the United Nations Convention on the Rights of the Child (UNCRC) does not call for an end to circumcision of minor boys. Jacobs argued that Article 30 of the UNCRC "awards children the right 'to profess and practice his or her own religion' (my emphasis). This recognizes children as members of religious communities. Also, if the framers of UNCRC wished to restrict religion to words and rites they would have limited themselves to the verb 'profess,' omitting 'practice.' The best reading of Art. 30 is that infant circumcision is permissible as a religious practice." [42A] In other words, the UNCRC would allow a boy to choose circumcision in alignment with his religious tradition long before he becomes an adult.

PROSELYTIZING MEN

The likelihood that a man will not just wish that he had been able to decide, but that he will be upset or angry with his parents' decision is small. The extent to which men are upset is largely caused by the actions of circumcision opponents who spread false, baseless, and hysterical claims about physical, sexual, and psychological harm. One of the more malicious aspects of intactivism is that it sows distrust of the medical profession to the point where a man is convinced that circumcision must be the cause of his physical or sexual problems. [43] If instead a man were to consult his physician or a urologist, he might be diagnosed, treated, and perhaps even cured of the condition.

Indeed, one goal of intactivists - as many circumcision opponents call themselves - is to convert happily circumcised men into angry men. For example, a man in a private intactivist Facebook group wrote, "No circumcised man should be happy that he is circumcised, they must be woken up and made angry." [44] Kristen O'Hara, author of Sex as Nature Intended It, lamented to me, "The one thing I hear over and over again is, 'I'm circumcised and I'm fine.'" [45] Earp states that circumcised "males who speak out and assert that they feel harmed are often ridiculed, derided, and dismissed." Yet he fails to add that men who are happy that they were circumcised during infancy are viciously ridiculed, derided, and dismissed - often by intactivists who are perpetually angry about their own circumcised organs. [46-48]

Advocates on both sides have recognized that circumcised men can be transformed from happy to angry by such hysteria. Lindsay Watson, author of Unspeakable Mutilations and co-author of the paper Circumcision Grief wrote that most circumcised men are in a state of "circumcision coma" - a blissful ignorance "from which they never awaken." However "a man, or boy, can be awakened from the circumcision coma by comments from within or outside the family, interacting with intact males, or, more commonly, today by information on the Internet." [49]

A group of pro-circumcision researchers observed that "[g]ullible men with little or no critical judgement or scientific understanding may succumb to the barrage of anti-circumcision arguments they read and become convinced that their circumcision is at the root of their sexual problems... The stress caused by a belief that they are victims of their newborn circumcision, and that they had no say in the 'circumcision decision', may lead such men to develop psychological problems." The researchers concluded, "Harm felt by some men likely stems from belief in pervasive anti-circumcision propaganda portraying circumcision as harmful." [50]

It's a game of chutzpah in which an army of keyboard intactivists proselytize men with hysterical and implausible claims. Then scholars like Earp step in and cite the gullible men as proof that circumcision harms men. Circumcision Choice has received several messages from men grateful for our articles that helped them to recover from intactivism. We received this (excerpted) note in December:

"By the time my last year of high school rolled around I discovered intactivism and because I was a dumb idiot I completely believed everything they said at face value. I wasn't educated in the subject matter so I just assumed they were right. I was indoctrinated into their movement and it made me feel really self-conscious and depressed. Intactivists like to say that their [sic] for body positivity but then they go around and would call me mutilated, broken and other names, it made me feel that way too. It was so bad it even ruined my sex life, I didn't have any problems previously before I met them. I went to college and I started to learn how to research properly. I come to find that there was a lot of conflicting scientific information. However, every single doctor, urologist, scientist that disagreed with the notion that circumcision has negative adverse effects was sent death threats and spam emails from intactivists. I'm so happy there's other people who realize how wrong intactivists movement really is. I'm on a path to recovery and body positivity so I can get back to where I was before. Thank you so much for your effort." [51]

PUSHBACK #1 - Women in societies where FGM is practiced defend the procedure and express positive feelings about it.

Male sexuality is viewed positively in the United States and many other nations where circumcision is practiced. Circumcision would be less popular if it actually reduced male sexual function or pleasure. By contrast cultures where female genital mutilation is practiced typically have negative views about female sexuality. Girls are taught to control their own pleasure. Consequently many view the FGM procedure as positive because it has the purpose and effect of reducing or eliminating sexual pleasure. Moreover, unlike the case of circumcision - in which there is widespread disagreement, medical authorities overwhelmingly recognize FGM as physically, psychologically, and sexually harmful. [52][53] Consequently any comparison between men's satisfaction with circumcision and women's satisfaction with FGM is incongruous.

ALTERNATIVES

Earp claims that not circumcising is "less medically risky than infant circumcision" because "virtually all of the health benefits of infant circumcision (primarily, a reduced risk of various infections or diseases) can be achieved by means that do not involve genital surgery, both in terms of prevention or treatment." He argues that one can achieve a reduced risk of infections and diseases by "regularly washing the genitals with mild soap and water [and] practicing safer sex strategies..."

The unfortunate reality is that many people don't practice safe sex and health habits. According to a 2013 AAP study just 60.2% of sexually active teens reported using a condom during their most recent sexual encounter. [54] A British study published in 2009 found that just 32% of men washed their hands with soap and water when using the restroom. [55] A 2013 Michigan State University study found that only 50% of men used soap. The average time spent washing hands was just 6 seconds - far less than the 20 seconds that the CDC recommends. [56] If men don't wash their hands properly, why does Earp assume that men will wash their genitals properly? Circumcision protects against infection - even for men who don't practice proper hygiene and safe sex.

Schaab pointed out that the rotavirus vaccine is on the vaccination schedule for 3 month-old infants. Rotavirus is an intestinal virus that is primarily contracted through an adult's bad hygiene habits, such as not washing hands. Rotarivus can be avoided if parents and other caregivers wash their hands before touching the baby's face. Using Earp's logic, rather than forcibly injecting the rotavirus vaccine, we should just tell people to wash their hands and not touch a baby's face. [36]

Earp states that "most UTIs are treatable non-surgically with antibiotics, as they are in [girls] (who get them much more frequently.)" Yet he fails to mention the limitations of antibiotics and ignores several unfortunate realities.

• Antibiotics often have harmful side effects, such as dizziness, diarrhea, nausea, and rashes. [57] Antibiotics for infants must be administered intravenously, which can cause pain and swelling.

• An increasing number of "nightmare UTIs" are resistant to all antibiotics. "New York City Department of Health ... research found that a third of uncomplicated urinary tract infections caused by E. coli - the most common type now - were resistant to Bactrim, one of the most widely used drugs, and at least one fifth of them were resistant to five other common treatments." (While antibiotics may be the only treatment option for girls, neonatal circumcision significantly reduces the likelihood that a boy might need antibiotics in the first place.) [58]

• More than half of pediatric UTIs are resistant to antibiotics, and boys are more likely than girls to contract an antibiotic resistant UTI. [59]

• Overuse of antibiotics can lead to antibiotic resistance, in which bacteria no longer respond to the drugs designed to kill them. At least 2 million Americans get infected with antibiotic resistant infections each year. [60]

• A 2009 study found that more than one-third of infants with normal urinary tracts who experience one UTI will have recurrent UTIs. [61]

His comparison between UTIs in boys and girls is misleading. Boys suffer approximately 70-90% of neonatal UTIs, which is when the risk of renal damage is higher. A study of approximately 1,000 febrile infants younger than 60 days found that "uncircumcised boys had the highest incidence of UTIs (21%), whereas circumcised boys (2%) and girls (5%) has similar incidences." UTIs are more common in girls later in infancy. [62][63]

Citing possible treatments for UTIs misses the point: not getting an infection is a medical benefit. It’s preferable to prevent an infection in the first place than to have to suffer the effects. The Hippocratic Oath that physicians take includes the promise, "I will prevent disease whenever I can, for prevention is preferable to a cure." [64][65]

INFORMED CONSENT

A key point that Earp emphasizes is that "it is the informed consent of the affected person ... that makes medically unnecessary genital cutting permissible as opposed to an impermissible bodily assault." Earp offered several hypothetical situations in his chapter. I will offer a few of my own. Consider the case of a 9 year-old boy who has suffered a series of UTIs and was treated by a regimen of antibiotics. After recovering from the latest UTI, he begs his parents to allow him to be circumcised like his 12 year-old circumcised brother who has never had a UTI. His parents chose not to have him circumcised at birth because they wanted it to be his decision; now they will consent to his preference. This situation is not merely hypothetical; it is one of many such stories reported in pro circumcision groups.

On what basis would a circumcision be unethical? One who argues that the patient lacks the ability to understand the procedure and its consequences would be passing judgment from a place of privilege. Earp maintains that from an ethical perspective, no one but the patient can provide consent because "the person(s) doing the weighing [of benefits and risks] are not the same person as the one who will be permanently affected by the procedure if it occurs." By that logic circumcision opponents cannot substitute their judgment for that of the suffering patient. If the decision properly rests with the one who must suffer the consequences, then a 9 year-old must be allowed to alleviate his own suffering via circumcision.

What about another member of the family, an 8 year old? Perhaps he's just had one UTI. He's aware that his 9 year-old brother suffered multiple UTIs that ceased following foreskin removal. He's also aware that his circumcised 12 year-old brother has had no urological problems. If the 8 year-old wants to be circumcised, how many UTIs must he endure until it becomes ethical to ease his suffering via circumcision? What if the boy is just 7? Or 6? How long must he wait and how much suffering must he endure until an ethicist would allow him to have a procedure that he is convinced - and that the experiences of his brother suggest - will end his suffering? Any law that would criminalize elective circumcision for minor boys would force all of these boys to continue to suffer the effects of the infections and the effects of antibiotics. That cannot be the ethical approach.

Now let's widen the focus. If the ethics are determined based on informed consent and not preventative benefits, there can be no logical reason why a 9 year-old should be able to elect circumcision for a preventative medical reason, but not for a religious or cultural reason. And the same logic would apply for younger brothers. Earp rejects any distinction between circumcision for preventative reasons and circumcision for religious or cultural reasons. Based on informed consent, any blanket prohibition of elective circumcision for minor boys would be unethical. One cannot insist that the choice must lie with the patient and then refuse to accept the patient's desire.

What about a family in which the two older brothers had problems with tight foreskins that required circumcision? This may be due to a hereditary condition. Should their younger brother be forced to endure the same problems? This, too, is not simply a hypothetical question. [66]

An ethicist has the luxury to sit back and cite statistics like just 1 in 900 men will get penile cancer - without considering families with a genetically higher risk. Again, not just a hypothetical situation. In December a mother in a pro circumcision group reported that she had circumcised her sons because both her grandfather and father had penile cancer - the latter being diagnosed at age 31. She wrote, "There are 5 risk factors to penile cancer, 4/5 are due to being uncircumcised" and "having it done later in life provides no protection" and "Watching my dad suffer had been horrendous." [67] Earp's position would be that her sons must be forced to have the genetic threat of penile cancer hanging over their lives. Again, that choice cannot be more ethical than the choice to protect them from cancer.

The ethics of circumcision Part 2

[1] Brian D. Earp; "The Ethics of Circumcision" - chapter in The Rowman & Littlefield Handbook of Bioethics; November 2022

[2] Brian D. Earp tweet; May 12, 2022

[3] Earp fails to clarify that for most primates, the prepuce is a sheath into which the entire penis retracts. By contrast the human foreskin is attached to the upper shaft and covers only the glans. The prepuce of a human female is called a clitoral hood, not a foreskin.

[4] The eyelid performs critical functions: keeping the eye moist and protecting the eye from excess light and harmful irritants. Without eyelids the eyes would dry out, gather dust particles, get infected, and eventually go blind. By contrast a circumcised man can use his penis for its intended functions - urination, procreation, and sexual pleasure - with no significant loss of function.

[5] Earp's only source for the protection against contaminants assertion is a 1999 paper by John Taylor and Christopher Cold. The authors, both circumcision opponents, provided no evidence for their assertion that the foreskin "decreas[es] external irritation or contamination" of the glans. On the contrary, studies show that circumcision provides protection against UTIs, STDs, and penile cancer.

[6] Earp claims that the foreskin measures "30 to 50 square centimeters" (4.65 - 7.75 in2.) That may be the average for both outer and inner surfaces, but most people would assume that an area measurement refers to one side or surface. For example, most people (including intactivists) would say that a 3" x 5" index card measures 15 square inches (based on one side,) not 30 square inches (based on both front and back sides.) A study of 965 men in Uganda reported that the average area for both surfaces was 6.0 in2 (39 cm2), which corresponds to 3.0 in2 (19 cm2) per surface. G Kigozi et al; "Foreskin surface area and HIV acquisition in Rakai, Uganda (size matters)"; AIDS; October 23, 2009. A Dutch study reported an average foreskin length of 15 cm2 (5.9 in2) and - when folded out - an average surface area of 46.7 cm2 (7.2 in2). However this study involved a total of eight cadavers. PM Werker et al; "The prepuce free flap: dissection feasibility study and clinical application of a super-thin new flap"; Plastic and reconstructive surgery; September 1998.

[7] Earp cites studies by Sorrells and Bossio. Sorrells did not measure sensitivity to heat. Bossio reported no significant differences in sensitivity to heat between circumcised and uncircumcised men. Jennnifer A. Bossio et al; "Does neonatal circumcision impact penile sensitivity in adult men? Examining penile sensitivity in circumcised and intact men using quantitative sensory testing"; Queens University; 2015. "We found no between-group differences in warmth detection thresholds on any (genital or non-genital) site tested. This finding is consistent with those reported by Bleustein and colleagues (2005), who assessed warmth detection thresholds in men with and without complaints of sexual dysfunction: no threshold differences were found based on circumcision status for either group of men."

[8] Earp declares that the foreskin is the most sensitive part of the penis to "light touch," again citing Sorrells and Bossio. Both researchers measured penile sensitivity to fine touch. Sorrells measured sensitivity using touch-test sensory evaluators. Bossio used modified von Frey filamints. Fine-touch is not the type of sensitivity applicable to most sexual activities. Vaginal sex, anal sex, and oral sex involve penile stimulation via friction caused by movement inside a partner's vaginal canal, anal cavity, or mouth. (Oral sex also typically involves penile and scrotal stimulation by a partner's tongue.) Masturbation typically involves stimulation by finger movement across the organ. These activities typically aren't limited to the type of static, fine-touch stimulation that Sorrells and Bossio measured.

[9] Earp's only source for the assertion is a 2006 survey by intactivist Peter J. Ball that was included in a book produced by anti-circumcision activists (George Denniston, Marilyn Milos). The survey was posted on an anti-circumcision website (NORM-UK) in the United Kingdom - a country where the population generally has an anti-circumcision bias. Subjects were recruited from foreskin-related internet discussion groups or were referred to the author. "The subjects were drawn from a variety of sources: men whose intact status was already known to me; referrals from these men, many of whom replied to an invitation to complete my questionnaire, which was placed on the NORM-UK website and on a naturist website; and some were recruited from subscribers to three Yahoo foreskin-related internet discussion groups. A large group came from men whose foreskins were too tight and who had sought advice via the NORM-UK website." This is precisely the type of low-quality study that Earp would eviscerate - if it were offered by a pro-circumcision apologist.

[10] Unlike circumcision, foot binding was practiced by no other culture outside of China - for good reason. The process took two years and was excruciatingly painful. The practice essentially imprisoned women "at home, unable to engage in everyday activities such as grocery shopping, because they had such difficulty walking." Foot binding caused severe physical impairment: significantly reduced circulation to the feet; ingrown toenails (in some case a girl's toenails were removed); softened bones; difficulty in balance, which increased the risk of falling and breaking other bones; paralysis and muscular atrophy; and toe and foot infections that led to septic shock and death. As many as 10% of girls died of gangrene or other infections. Many became disabled. A circumcision properly performed rarely affects the three functions of the penis. By contrast binding was designed to impede the normal functions of the foot. Foot binding offered no medical benefits, only a lifetime of pain and misery.

[11] Earp cites a 2010 AAP statement "Ritual Genital Cutting of Female Minors." The AAP did not say nor suggest that prohibiting FGM while allowing circumcision is discriminatory. (The word "discriminate" does not appear in the AAP statement in any form.) Rather, the AAP expressed a concern that a complete FGM ban might subject girls to being sent "back to their home country for a much more severe and dangerous procedure." The AAP stated that a "ritual nick ... is not physically harmful" and suggested that a more effective approach might include physicians having the legal ability to offer families "a ritual nick as a possible compromise to avoid greater harm." The AAP saw this option as a temporary measure to "build trust," prevent "disfiguring and life-threatening procedures," and "play a role in the eventual eradication" of FGM.

[12] Morten Frisch M.D. et al; "Cultural Bias in the AAP's 2012 Technical Report and Policy Statement on Male Circumcision"; Pediatrics; April 1, 2013.

[13] Susan Blank M.D. et al; "Cultural Bias and Circumcision: The AAP Task Force on Circumcision Responds"; Pediatrics; April 1, 2013

[14] "Newborn male circumcision position statement"; Canadian Paediatric Society; September 8, 2015. (The CPS reaffirmed its policy statement in 2021.) "The parents of male newborns must receive the most up-to-date, unbiased and personalized medical information about neonatal circumcision, so that they can weigh specific risks and benefits of circumcision in the context of their own familial, religious and cultural beliefs. Parents who choose to have their sons circumcised should be referred to a practitioner who is trained in the procedure."

[15] "Omskæring af drenge uden medicinsk indikation er etisk uacceptabelt"; Sveriges Läkarförbund; November 5, 2020

[16] Earp states that the DMA concluded that circumcision provided no clear medical benefit "prior to sexual debut." He has supported legislation that would prevent a sexually active teen from electing circumcision before his 18th birthday. In 2020 the U.S. Centers for Disease Control released the results of a national survey taken during 2015-2017. The CDC reported that 48% of boys had engaged in sexual intercourse by age 17, and 62% by age 18.

[17] The HIV status of the participants was determined by objective laboratory tests and thus was not subject to a placebo effect. Participants were either HIV-positive or not. The study was not like a drug trial in which subjects are asked questions about their subjective symptoms, such as pain or fatigue, for which a double-blind study would be important.

[18] In the trial some HIV-positive men infected their partners because they resumed sex before the circumcision wound had healed. This wouldn't be an issue for partners of men circumcised in infancy.

[19] Fatti G et al; "Low HIV incidence in pregnant and postpartum women receiving a community-based combination HIV prevention intervention in a high HIV incidence setting in South Africa"; PLoS One; 2017. Jean K et al; "HIV incidence among women is associated with their partners' circumcision status in the township of Orange Farm (South Africa) where the male circumcision roll-out rate is ongoing"; International AIDS Conference; 2014

[20] Surgical risk refers to an unplanned or unexpected outcome. Consider mastectomy, the surgical removal of a breast. The loss of a breast is planned and expected; indeed, it's the definition of the procedure. So loss of a breast is not considered a risk of mastectomy - even if the procedure is elective. Similarly, the definition of circumcision is removal of the foreskin. Since foreskin removal is planned and expected, the loss of foreskin is not considered a surgical risk.

[21] Barriers to adult circumcision include: cost (which often isn't covered by insurance, and may range from $800 - $6,530); reduction in benefits (no protection against penile cancer and limited protection against UTIs); recovery (the penis will be particularly sensitive for up to two weeks); disruption of normal activities (a patient must take one or more weeks off work or school); involuntary abstinence (a patient must refrain from sexual activity for four weeks); and fear of pain or embarrassment. These obstacles don't apply to men who were circumcised during infancy.

[22] Earp discusses the risk of accidental glans amputation - a risk so rare (especially in the U.S.) that there are only case reports. By contrast the lifetime risk of penile cancer is about 1 in 900, or 0.11%. The American Cancer Society estimates that about 2,050 cases of penile cancer will be diagnosed in the United States in 2023, and about 470 men will die from the disease. Most penile "cancers start on the foreskin... or on the glans." "Surgery is the most common treatment for... penile cancer." If the tumor is on the glans, part or all of the glans may be removed. Thus the lifetime risk that the glans (or the entire penis) will be amputated is significantly greater if an infant is not circumcised than if he is.

[23] Unlike circumcision, there are no preventative medical benefits to earlobe removal.

[24] Earp cites a neonatal/infant complication rate of 1.5% from a 2010 systematic review. Yet he ignores the next sentence, which reported a 6% complication rate for older children. Instead he cites an adult complication rate of 1.7-3.8% from a 2011 study. However the previous sentence listed a neonatal complication rate of 0.2-0.6%. In other words, the data from the 2010 review showed that delaying the procedure increases the complication rate by a factor of 3; and the 2011 study showed that a delay increases the complication rate by a factor of 6.75. Earp deceptively cherry-picked the data in order to make the absurd claim that the risk for infant circumcision "is not very much lower, in absolute terms, than the risk" for adult circumcision.

[25] A 2013 Canadian study reported that 82.2% of couples in which the father was circumcised believed that circumcision by an experienced medical practitioner was a safe procedure for all boys; none responded that circumcision was unsafe. A 2015 YouGov survey of American men reported that 86% of circumcised men and 67% of uncircumcised men were satisfied with their circumcision status. Just 10% of circumcised men and 29% of uncircumcised men wished that they were the opposite status. A 2017 study in Israel found that 98% of parents circumcised their sons; 96% of parents under age 30 said they had no doubts about the decision. Earlier Earp had stated as a parenthetical that parents wouldn't knowingly subject their sons to circumcision "unless they were, for example, sadists or psychopaths; but we can assume such a situation is rare." Therefore Earp bears the burden of proof to show that a significant number of fathers who choose to circumcise their sons are dissatisfied with their own circumcised genitals.

[26] For example, see: S Woods; "Ethical approach to genital examination in children"; Paediatrics & Child Health; 1999. Heather Felton, M.D.; "Physical Exams at the Pediatrician: What to Know"; University of Louisville Health; February 27, 2018. Miranda Hester; "How to overcome discomfort with the genital exam"; Contemporary Pediatrics; October 5, 2020. "Child and Adolescent Male Genital Examination"; Australian Government Department of Health; March 2021. "Patient/Family Guide to Pediatric Sensitive Exams"; Michigan State University Health Care.

[27] Aesop; "The Fox & the Grapes"; The Aesop for Children; Library of Congress; 1887

[28] Brian D. Earp et al; "False beliefs predict increased circumcision satisfaction in a sample of US American men"; Culture, Health & Sexuality; July 2018

[29] Andrew Gross; "Do happily circumcised men have false beliefs?"; Circumcision Choice; April 11, 2020

[30] Stephen Moreton; "Do False Beliefs Predict Increased Circumcision Satisfaction in Men?"; Advances in Sexual Medicine; April 17, 2020

[31] Robert Zulu et al; "Sexual Satisfaction, Performance, and Partner Response Following Voluntary Medical Male Circumcision in Zambia: The Spear and Shield Project"; Global Health:Science and Practice; 2015

[32] John N. Krieger M.D. et al; "Adult Male Circumcision: Effects on Sexual Function and Sexual Satisfaction in Kisumu, Kenya"; Journal of Sexual Medicine; November 2008

[33] M.O. Brito; "Sexual Pleasure and Function, Coital Trauma, and Sex Behaviors After Voluntary Medical Male Circumcision Among Men in the Dominican Republic"; Journal of Sexual Medicine; April 2017

[34] See for example: Joao Paulo Zambon et al; "Urological complications in women with genital mutilation"; Clinical and Medical Reports; 2018

[35] Melanie Lindwall Schaab; private message to Andrew Gross; February 5, 2023

[36] Melanie Lindwall Schaab; private message to Andrew Gross; February 23, 2023

[37] Joseph Mazor; "The child's interests and the case for the permissibility of male infant circumcision"; BMJ Journal of Medical Ethics; January 2013

[38] Melanie Lindwall Schaab; "A Summary of the Ethics of Infant Male Circumcision"; Elephant in the Hospital Facebook group

[39] Dominic Wilkinson and Julian Savulescu; "Ethics, conflict and medical treatment for children"; National Library of Medicine; September 4, 2018

[40] While Hindism discourages non-medical circumcision, I've seen no evidence that a male would be prohibited from conversion to that religion based on a pre-existing circumcision status. As far as I'm aware, the only religious groups where circumcision would pose a problem are some ascetic sects in India that shun all sexual activities. For more information see The Hard Truth About Erections (footnotes 13-14.) I will concede the possibility - albeit highly unlikely - that an American male may grow up to join an ascetic Indian sect if Earp will concede that it's exponentially more likely that an American male will be diagnosed with penile cancer during his lifetime.

[41] Wesley J. Smith; "Bioethicist Claims Allowing Circumcision Is Sexist"; National Review The Corner; October 26, 2021

[42] Rhys Southan; "The First Cut"; Aeon; September 9, 2014

[42A] Allan J. Jacobs; "The Ethics of Circumcision of Male Infants"; Israel Medical Association Journal; January 2013

[43] The Circumcision Choice article Is intactivism a cult? has examples in which parents were so distrustful of the medical profession, that they hesitated to seek medical treatment for their children who suffered serious medical conditions.

[44] Colton Harrelson; Intactivist Trauma Relief Facebook group post; February 4, 2019. "It is unacceptable that there are people who are circumcised and happy that they are circumcised, and appreciate it. It is important that every circumcised man feels like we do so that progress can be made into banning routine neonatal male circumcision... No circumcised man should be happy that he is circumcised, they must be woken up and made angry. This will certainly give us the attention we want, and actions we desire from lawmakers, government, and medical community." See also: "Is there an intactivist tipping point?"; Circumcision Choice; November 2, 2019.

[45] Kristen O’Hara; emails to Andrew Gross; March 2, 2015. "I have spoken and corresponded with many men over the years on the circumcision topic. The one thing I hear over and over again is, ‘I'm circumcised and I'm fine.’ So it became apparent that if we had any hope of getting this topic out in the open, the only hope we had was in making this a women’s issue, since women would not have their sexual egos involved."

[46] For example: James Loewen, comment on "Intactivists remember Conte, try to deliver petitions to AAP"; Bay Area Reporter; October 27, 2016. "What do you like best about having a scarred, less functional penis than what nature provided?"

[47] For example: Seth Edward; Facebook comments; May 19, 2019. "What didn't you like about having a fully functional, whole, normal penis?"; "'tHaNkS mOm FoR GIVINg mE a sMaLLeR PeNiS!' - said no intelligent man ever."

[48] For example: Carter Steinhoff tweet; September 4, 2022. "You're a grade A cuck, Bob. You were genitally mutilated as a fragile infant by your shitty, brain dead parents, and you're now pathetically trying to justify it. It's time you go waddle on back to weenie hut jr's where you belong."

[49] Lindsay R. Watson; "Unspeakable Mutilations: Circumcised Men Speak Out"; CreateSpace Publishing; June 20, 2014.

[50] Stefan A. Bailis, et al; "Tye & Sardi’s Psychological, Psychosocial, and Psychosexual Aspects of Penile Circumcision"; Advances in Sexual Medicine; July 2022

[51] T.; email to Circumcision Choice; December 4, 2022. (name redacted)

[52] Kathryn M. Yount, Bisrat K. Abraham; "Female genital cutting and HIV/AIDS among Kenyan women"; Studies in Family Planning; June 2007

[53] A 2010 study of Kenyan women and girls reported an inverse correlation between FGM and HIV/AIDS. Rosemary G. Kinuthia; "The Association between Female Genital Mutilation (FGM) and the Risk of HIV/AIDS in Kenyan Girls and Women (15-49 Years)"; Georgia State University; Spring 2010

[54] Rebecca F. O'Briend M.D., et al; "Condom Use by Adolescents"; Pediatrics; November 2013

[55] Gaby Judah B.A. et al; "Experimental Pretesting of Hand-Washing Interventions in a Natural Setting"; American Journal of Public Health; October 2009

[56] Andy Henion & Carl Borchgrevink; "Eww! Only 5 percent wash hands correctly"; MSU Today; June 10, 2013

[57] "Antibiotics Aren't Always the Answer"; U.S. Centers for Disease Control; August 23, 2018

[58] Matt Richtel; "Urinary tract infections affect millions. The cures are faltering"; New York Times; July 13, 2019

[59] "What About Antibiotics?"; Circumcision Facts and Science; January 27, 2022

[60] "Antibiotic Resistance Threats in the United States - 2019"; U.S. Centers for Disease Control and Prevention; December 2019

[61] Yoon Hee Shim et al; "The risk factors of recurrent urinary tract infection in infants with normal urinary systems"; Pediatric Nephrology; February 1, 2009

[62] Clin Perinatol; "Urinary Tract Infections in the Infant"; Clinics in Perinatology; March 2015.

[63] Cassandra Coleman et al; "Neonatal Acute Kidney Injury"; Frontiers in Pediatrics; April 7, 2022. "Acute kidney injury (AKI) occurs commonly in the neonatal intensive care unit (NICU) and is associated with increase [sic] morbidity and mortality. Furthermore, those who develop neonatal AKI may be at increased risk for the development of chronic kidney disease (CKD)."

[64] Louis Lasagna; "The Hippocratic Oath: Modern Version"; 1964

[65] Peter Tyson; "The Hippocratic Oath Today"; PBS Nova; March 26, 2001

[66] Marky41667191 tweet; November 30, 2022

[67] CL; post in Pro Circumcision Parents Facebook group; December 29, 2022. (name redacted)

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