How Insensitive

Controversy in scientific research is hardly unique to the subject of male circumcision, but the procedure itself does pose unique challenges to the investigator. The first of these is determining who is actually circumcised. In some studies, researchers simply asked participants — or their female partners — if the penis in question was intact or not. But circumcision skeptics say asking doesn’t cut it. Bob Van Howe, co-author of a recent study showing that circumcision removes the most sensitive parts of the penis, cites research showing that both men and women are wrong about the circumcision status of the penis between five and thirty percent of the time. (I found this statistic implausible until I asked my mother whether my father — to whom she’d been married for eighteen years and with whom she’d had two children — was circumcised. She didn’t know.)

Even after figuring out who’s cut and uncut, the researcher confronts epidemiologically significant cultural and religious questions that can turn painstakingly designed studies into the equivalent of a leaky condom. In Africa, as elsewhere, Muslim men are more likely to be circumcised and less likely to be HIV-positive. Is that because their circumcision is protecting them, or because of the way religion and ritual affect their sexual behavior and genital hygiene? In England, circumcision rates among older men are class-determined. Are HIV rates among the gentry low because they’re missing a prepuce, because of the sex practices of the English upper class, or because of the education and health care they can afford? In the U.S., Hispanics are less likely to be circumcised than African-Americans, and less likely to be HIV-positive. Again, is that a function of cultural affiliation and sexual behavior, or of foreskin?

In Africa, circumcision research faces even knottier challenges. One study published this year showed that sub-Saharan African adolescents and virgins were significantly more likely to infected with HIV if they were circumcised, probably because they were infected by the instruments used to circumcise them. But among circumcised adults, HIV rates were lower. Instead of indicating that foreskin was the culprit in spreading HIV, the study authors suggested, this lower HIV prevalence may simply be because a significant number of men who were circumcised as boys in Kenya, Lesotho and Tanzania didn’t survive their circumcisions long enough to be studied.

So is it any surprise that circumcision studies are so frequently at odds with each other? From the studies I’ve reviewed for this story, I could use peer-reviewed scientific evidence to support the notion that circumcision results in higher rates of infection with herpes type 2, or lower

rates of herpes type 2, or higher rates of infection but lower incidents of herpes outbreaks. I could argue that circumcision helps prevent HPV and anogenital and cervical cancer or that it has no effect. I could argue that the West has an obligation to help Africa get circumcised or that it has an obligation to leave African penises alone.

But even if the medical establishment arrived at an undisputed consensus, I’ll keep thinking about the well intentioned parents — and doctors — in the nineteenth century who circumcised millions of boys to protect them from hip dysplasia. Doesn’t that history give us a special obligation to be cautious?

Circumcision proponents say that amounts to tainting them by association with yesterday’s crackpots. "One can find absurd statements about almost anything if one searches for them," said Robert Bailey, professor of epidemiology at the School of Public Health at the University of Illinois at Chicago, and the principal investigator for the Kenya study. "There is a lunatic fringe advocating for or against nearly every medical treatment ever proposed."

But the nineteenth century argument linking circumcision, masturbation and epilepsy didn’t belong to the lunatic fringe. It belonged to the medical establishment. Respected researchers in major medical journals and textbooks urged doctors to amputate the foreskin of men and boys to prevent them from jerking off and contracting the debilitating disorders, physical and otherwise, that masturbation was thought to cause.

How will future generations judge today’s medical establishment on the question of circumcision? Surely scientific research today is more rigorous than it was in the nineteenth century. In the coming century, it will be more rigorous still. Personally, if I’m ever in the position of deciding whether an infant is going to have the most sensitive part of his penis cut off in exchange for potential health benefits later in life, the full range of what They have been telling us over the last 150 years is going to raise a red flag.  n°

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