STEPHEN MORETON believes that it is very important that people in the secular/atheist camp, as well as others, treat anti-circumcision activists with caution.

IF a religion taught that its followers must vaccinate its non-consenting children because the great sky daddy said they must, we might think the reason given was daft, but we would not complain. After all, the outcome is a good one. But what if that preventative medicine is male circumcision (MC)?

The current bid to ban religious MC in Iceland has revealed a dark, and hypocritical, side of the humanist, atheist, secular and sceptic movements. People who pride themselves on being big on science and reason toss them aside in the rush to jump on the anti-circumcision bandwagon, seeing the procedure as a convenient stick to bash religion with.

Scientific evidence is drowned out by emotional rhetoric: it’s “mutilation”, “child abuse”, a “violation of human rights”, and stupid comparisons are made with removing ear lobes, breasts or other body parts. And in jumping on this bandwagon they are rubbing shoulders with some very distasteful characters – the “intactivists”.

Intactivism is the name given by its followers to the anti-circumcision movement. The idea is that an “intact” man still has a foreskin. Originating in the USA, they dominate the Internet. Any article on MC attracts a host of hostile comments. Try answering them with reason and evidence and expect to be called a “paedophile”, “knife rapist”, “liar”. Intactivists monitor Facebook 24 hours a day watching out for parents mentioning having their sons circumcised. This is then flagged in their groups so that others can target the hapless parents with vile abuse and threats. Their cult master “Brother K” (Kenneth David Hopkins) leads the bullies with thousands of minions watching, reporting and harassing.

Doctors, surgeons and mohelim providing the procedure are targeted with abuse, campaigns to get them sacked, and death threats. Amongst themselves intactivists share strangers’ Facebook images and comments along with epithets like “I want to smack her face in with a baseball bat”. They gloated over the Malasian Airways flight 17 disaster in 2014 because some on board were going to an international AIDS conference with sessions on male circumcision, and others celebrate the Holocaust because it means fewer Jewish people, therefore fewer circumcisions.

They spread pseudoscience designed to deceive impressionable males into thinking they are missing something wonderful, the most erogenous part. That this causes psychological harm concerns them not. In fact it is their intention to make circumcised males angry as it draws motivated new recruits into their movement. They have even set a target: 600,000 angry circumcised men, which they hope will be enough to achieve their goal – a ban on infant circumcision. So far they have driven one young man to suicide, maybe two, and caused needless distress amongst others deceived by this narrative.

Cult-like: Brother K (original name Kenneth David Hopkins) has become something of a cult-leader in the intactivist movement.

Their rhetoric is identical to that emanating from the supposedly rational secularist camp. It is anything but rational. “Mutilation” in its widest sense means any bodily modification, so a vaccination that leaves a scar is a mutilation. In its usual sense it means harm or disfigurement. But as MC is neither it is not mutilation. Those who cry “mutilation” are engaging in cheap emotional point-scoring, like those who call abortion “murder”.

As for “child abuse”, comparing a trivial medical procedure under local anaesthetic to years of beating or sexual violation is preposterous. And if rights are one’s concern, does the right to keep every bodily part, no matter how unimportant, trump the right to have one’s health, even life, protected? And the comparison with removing ear lobes etc is inane. Have these idiots not heard of a risk/benefit analysis?
I say, “wait a moment, let’s look at the science”. And there is a lot of it. Searching PubMed (the principle search engine for the medical scientific literature) for “circumcision public health” throws up 3,499 hits, a search on “circumcision HIV” 1,724 hits. By the time you read this those numbers will have increased as new studies are being published all the time. At my last count I had more than 1,100 of them on my computer, an extensive library on the topic being essential if one is to contribute effectively to the debate – which I do through the website which I edit and write for.

It is one of the few devoted to exposing anti-circumcision pseudoscience. Sadly, having seen the appalling ignorance in comments threads on humanist, sceptic and secular media, it appears I probably know more about this topic than all those commenters combined.

So what does the science say? Well two things. First, MC has no adverse effect on sexual function, sensation or satisfaction. And secondly it has an impressive list of proven benefits.

Dealing with sexual function first, there are dozens of studies on the effect of MC on sexual function and pleasure, mostly survey-based cross-sectional affairs, subject to the weaknesses inherent to such study designs, such as small sample sizes, selection bias, confounding and leading questions. Even so, the great majority find no effect, a few find a positive effect, and a few find negative ones. The most obvious conclusion from that alone is that male circumcision has no significant effect, and all we are seeing with the few studies that purport to find one (whether for better or worse) is statistical noise.

But not all studies are equal. Some are of inherently better design than others (ie less likely to suffer from biases and confounding). At the bottom of the pile are opinions and personal testimonies, a little higher up individual case reports, higher again ecological studies (eg country-by-country comparisons), middle ranking are cross-sectional studies (typically survey–based), higher again case-control studies, then cohort studies and then the best of all study designs, the randomised controlled trial (RCT), often referred to as the “gold standard” of epidemiology. Well-conducted systematic reviews and meta-analyses are right at the top.

Most studies on sexual function do not get past cross-sectional. When one looks at the best designed studies, ie higher up the hierarchy of evidence, something interesting happens. There are eight primary studies, including three RCTs, plus a further four systematic reviews incorporating two meta-analyses. Every one of them finds either no adverse effect, or a positive one (eg less pain on intercourse), leaving the intactivists to cherry-pick the handful of weaker studies finding a negative effect.

And cherry-pick they do. When Dr Antony Lempert, chair of the National Secular Society’s Secular Medical Forum, participated in a debate at UCL in 2013, he regaled his audience with a few studies purporting to find that MC had detrimental effects on sexual pleasure or function. He ignored the majority of studies finding no difference, including several measuring sensitivity in various ways, and RCTs looking at men circumcised as adults and thus able to compare.

In one the men even reported increased sensitivity following circumcision. He also omitted to mention the severe criticisms his cherry-picked studies had attracted. The first two were so bad (marred by statistical flaws and selection bias) as to be almost worthless. The third study, from Denmark (and which was still problematical) he misrepresented, saying it found, “circumcision was associated with a range of frequent sexual and orgasm difficulties in female partners of circumcised men, as well as the men themselves”.

Yet Morten Frisch, the lead author of that study, and a staunch opponent of circumcision, has gone on record as saying, “most circumcised men and most spouses of circumcised men did absolutely well in their sex lives” and “most women with circumcised spouses do not encounter a whole lot of sexual trouble. That I want to stress to avoid stigmatisation”.

In short, not only did Dr Lempert cherry-pick the data, he even misrepresented some of the data he cherry-picked. Sadly, this behaviour is standard practice for circumcision opponents. I used this example only to show that even people in our non-religious camp are guilty. Every study they cite can typically be matched with a greater number of often better quality studies that say something different. That is normal for pseudoscience.

Also normal is the use of bogus statistics, speculations and internet memes passed off as genuine. Claims of foreskins containing 10,000, 20,000, 70,000 (take your pick) nerves, involved in the ejaculation reflex, covering 15 square inches, having 16 functions, 117 babies dying each year from MC complications, only one in 16,667 boys ever needing a circumcision, 20 percent getting meatal stenosis following MC, and all ending up with a hardened, desensitised glans, and many other extravagant claims, have all been debunked ad nauseam. Yet notable people in the sceptical community have fallen for some of these myths (Myles Power and Marianne Baker come to mind). And one, Deborah Hyde editor of The Skeptic, twice gave space to intactivist articles packed with misleading, even dishonest, claims, and refused to allow a rebuttal to the second of those articles.

MC has benefits. It protects against: urinary tract infections (life-threatening in the neonate, and increasingly antibiotic-resistant), balanitis, posthitis, candidiasis, penile cancer, prostate cancer, phimosis and complications thereof (paraphimosis, gangrene, necrotising fasciitis), lichen sclerosis; and sexually transmitted infections: HIV, oncogenic HPV, HSV, syphilis, Mycoplasma genitalium, Trichomonas vaginalis, genital ulcerative disease and chancroid.

Females are protected also, as their male partners are less likely to be infected. This includes a lower risk of cervical cancer caused by oncogenic HPV.

Many of these benefits apply throughout childhood, and it will not do to counter the sex-related ones with the cry, “Condoms!” One will never get all men to use condoms, or use them consistently, or use them properly every time they do. Besides, even when used consistently they are only about 80 percent effective at stopping HIV transmission according to a Cochrane Review, 71–77 percent effective according to the latest meta-analysis. As shown by the HIV tragedy in Africa, where the epidemic continues despite massive condom promotion, something more is needed.

That something more is MC. Around 40 epidemiological studies, the great majority finding an association between foreskins and contracting HIV, culminated in three RCTs (in Uganda, Kenya and South Africa) that clinched it. MC is highly protective against female to male transmission, the two most recent meta-analyses find 70 & 72 percent efficacy. That is awesome, and compares with the effectiveness of influenza vaccine against the flu.

Concurrently, a considerable body of research has identified several mechanisms by which the virus gains entry. The foreskin is the weak point that lets the virus in. Take it away and that main route of entry is denied. It can still find other ways, but the risk is much reduced.

This has led the WHO, CDC, UNAIDS, PEPFAR, Bill & Melinda Gates Foundation, Marie Stopes and others to promote MC in Africa where the epidemic is at its worst, although it is also being considered for parts of the Caribbean, Asia and Far East where there are HIV hotspots. Originally targeting adults, by 2016 some 14.5 million Africans had volunteered for the cut, 2.8 million in 2016 alone as the programme escalated. And where it is being rolled out HIV incidence is starting to fall, more so in men than women, as male circumcision protects men directly. And the programme is now being extended to infants.

This is as good as it gets in medical science. Tens of epidemiological studies, most indicating an effect, three RCTs and a series of systematic reviews and meta-analyses confirming it, likely mechanisms identified, and now real-world data with evidence of a dose-response relationship. One cannot ask for better. Faced with an epidemic of an incurable disease, that has defied all attempts at developing a vaccine, and that has killed 35 million and infected as many more, this is fantastic!

The anti-circumcisionists are in apoplexy over this. They divide into the outright deniers, and the “yes buts”. From the deniers, pseudoscientific arguments abound, disputing the data, pointing to “methodological flaws”, or anomalies where circumcised men are evidently more likely to have HIV. All have been debunked, often in excruciating detail, and to the satisfaction of every professional body dealing with the epidemic.

The “yes buts” take a superficially more reasonable view. “Yes, circumcision can protect against HIV” they admit, “But wait until the boy is old enough to choose for himself if he wishes to be circumcised”. Those who take this line have obviously not experienced an erection held together by a dozen to twenty stitches.

In fact there are a whole string of reasons why infant male circumcision is preferable over adult. It is less risky, less costly (no need for time off work), less painful (local anaesthetic, and no troublesome erections), heals faster, and there is no need to abstain from sex for six weeks until it heals up. All these are major deterrents for adults, as identified by numerous studies.

When educated about the benefits of MC, many men are positive about the idea, but are deterred by the aforementioned barriers. But majorities, sometimes very large ones (over 90 percent) would have a son circumcised. In a situation where getting as high an uptake as possible is vital, this is hugely important. It means tens of millions more circumcised males a few decades hence, and thus millions of new HIV infections averted by the end of the century. It is a no-brainer: it is not worth infecting millions with a deadly disease for the sake of a bit of skin. Yet still dogmatic anti-circumcisionists oppose it.

Now, whether MC is of use outside HIV epidemic settings is currently a hotly debated topic. But risk/benefit and cost/benefit analyses are appearing in the literature indicating that it might be. In 2012 the American Academy of Pediatrics (AAP) conducted the most extensive review of the literature up to that point. It concluded that the benefits of male circumcision outweigh the risks, and it should be made available to parents who choose it, but stopped short of recommending it be routine. A storm followed in the medical literature, with accusations of “cultural bias” being thrown in both directions, and attempts to rebut the AAP’s findings meeting with counter-rebuttals, followed by counter-counter-rebuttals. It is still grumbling on.

The Centers for Disease Control and Prevention (CDC) soon came to the same conclusion as the AAP, leading to another round of rebuttals and counter-rebuttals. Then the Canadian Pediatric Society published its review in 2015, this time taking a more nuanced position – the risk/benefit ratio they concluded was “closely balanced”, and so they erred on the conservative side. Again the usual round of rebuttals etc followed, as did a risk/benefit analysis finding that male circumcision does win even in a low HIV setting, and does so comfortably.

Meanwhile, just as the science is moving in favour of the procedure, public opinion is going the other way. And sadly, the European medical bodies, especially the Dutch and Nordic ones (for whom male circumcision is very much against their culture) are following public opinion instead of the science. No European body has attempted an up-to-date comprehensive review of the scientific data, and their (often outdated) policy statements seem to be more ideology than science-based. This trend has grave implications.

Thankfully, the WHO and other bodies promoting MC take no notice of the foreskin fans, and the programme continues. Unfortunately Africans do take notice, and intactivists are organising on the continent and targeting them with pseudoscience and scare-mongering. And they are very intently watching developments in Europe.

Their Facebook pages (eg Intact Africa, Intact Kenya, Nairobi Circumcision Resources) routinely post reports of moves to ban MC in the developed world, including the current attempt in Iceland.

So just when they are being told by the WHO etc to circumcise, they see Europeans saying this is wrong, or not good enough for them. What a dangerous message to be sending out.

Meanwhile, what if the MC advocates are right? Suppose the procedure really does have benefits that outweigh the risks? If so then MC is not “mutilation” it is preventative medicine that just happens to have religious and cultural significance for some. In which case, religious MC is an example of doing the right thing for the wrong reason.

The answer is to regulate the procedure. Insist it be done by medically trained practitioners, to avoid tragedies such as Goodluck Caubergs, attacked in 2010 by a woman with a pair of scissors in Greater Manchester. He bled to death. Right now any Tom, Dick or Abdul can go around with a sharp instrument cutting babies and get away with it, so long as the baby does not end up in intensive care, or dead.

This is outrageous. But it is not outrageous to want for one’s son a simple, evidence-based, prophylactic medical procedure that will protect him for life from a wide range of conditions, some serious, and some common. By all means campaign for regulation of MC, but not prohibition. Let the science settle that, and right now the science is moving in male circumcision’s favour.

• Stephen Moreton PhD is a research chemist based in Cheshire, England. He is a long-standing atheist, sceptic and debunker of pseudoscience, who has been following the intactivist movement for years, and views it as a dangerous pseudoscientific cult. He edits and writes for the debunking website, one of the few dedicated to exposing anti-circumcision pseudoscience.