Thursday, May 27, 2010


A man's opinion on the subject of circumcision more often than not reflects the state of his own foreskin. The majority of men in this country are circumcised as infants and, therefore, have no memory of what it was like to have an intact member. They don't remember the pain of being circumcised and they are, more often than not, content with the appearance and function of their penis (and if they're not content, it usually has nothing to do with their lack of foreskin). On the other hand, most men who reach adulthood with intact foreskins are equally content with the appearance and function of their penis.

A woman's opinion of circumcision is more variable. European women, who are unaccustomed to circumcised penises, think that they are pretty funny-looking, and will generally prefer an uncircumcised man. American women, who are accustomed to circumcision, may think that foreskins are a bit strange. Fortunately for men from both camps, any woman worth having is smart enough to judge a man on qualities other than the presence or lack of a quarter ounce of skin (in truth, I have no idea how much an adult foreskin weighs, but you get the idea).

There have been quite a few studies evaluating the health risks and benefits of circumcision. If you ask the rabid anti-circumcision activists, they will cite the studies that found higher rates of erectile dysfunction in circumcised men, lower sensitivity of the glans of the penis in circumcised men and significantly reduced satisfaction with masturbation. They will also tell you the horror stories about circumcisions gone wrong, where more than the foreskin was removed or where post-surgical infections had disastrous, even deadly consequences. On the other hand, if you visit, a decidedly pro-circumcision website, you will find citations from studies showing that circumcision reduces rates of erectile dysfunction and increases sexual satisfaction. Interestingly, pro-circumcision advocates will either argue that circumcision increases the sensitivity of the glans of the penis, which sounds good, or they will argue that it decreases the sensitivity, which is also good... because it allows men to last longer during sex. Considering that men may experience either the problem of too much sensitivity or too little, its not clear to me that either change can be considered of universal benefit. The results of all of these studies add up to very few if any statistically significant results, and about as many anti-circumcision results as pro.

The most compelling argument for circumcision, since there is no consistent evidence of harm or benefit in terms of sexual function, comes from the studies relating to rates of disease in circumcised versus uncircumcised men. Advocates of circumcision will tell you that uncircumcised men have ten times the risk of penile cancer as compared to circumcised men. And the risk of penile cancer is related to other diseases that occur in greater frequency in uncircumcised men, including HPV, HIV and phimosis. However, the risk of penile cancer in American men is only 1 in 100,000. Therefore, we would have to do tens of thousands of circumcisions to prevent one case of penile cancer. And as rare as complications of circumcision are, for every ten thousand circumcisions we do, at least a few will result in serious complications. In essence, by performing neonatal circumcisions, we are trading the extremely slim possibility of disease in the older adult male for a similar possibility of serious iatrogenic complications beginning in infancy. Virtually all of the diseases that circumcision is purported to be protective against can be traced to poor hygiene. The most significant studies in defense of circumcision were performed in Africa, where access to clean water, condoms and changes in dangerous sexual practices, would have a more profound positive effect than would circumcising the entire population. In the Unites States, the incidence of these diseases is quite low and the means to prevent them, without circumcision, are readily available. Studies performed regarding circumcision in third world countries, therefore bear little relevance to the risks facing men in the U.S.

The American Academy of Pediatrics has a very comprehensive policy statement regarding circumcision, which they revise frequently to reflect the most recent research regarding the possible health benefits of circumcision. However, they, like virtually every other respected medical society, ultimately conclude that the potential benefits of neonatal circumcision are insufficient to make a recommendation.

I would hazard a guess that most parents are not making the decision of whether to circumcise their sons based on their careful appraisal of its potential health benefits. Rather, they are making the decision based on one factor: Dad. If Dad is circumcised, then circumcision is the obvious, normal choice. Circumcised Dad will, no doubt, worry that his son will be the subject of locker room bullying if his penis does not conform to American standards. Circumcised Dad will assume the worst about the consequences of going uncircumcised and will latch onto the studies which indicate the vast dangers of possessing a foreskin. Ultimately, Circumcised Dad will be compelled to take the path of least resistance, which for him is to obey tradition and not question the decision that his own parents made for him. Uncircumcised Dad, of course, has no such concerns. He knows that, even if he did get curious looks in the locker room growing up, the rates of circumcision are steadily dropping so that nearly half the other boys in the locker room in the future will also be in possession of a foreskin. Uncircumcised Dad pays careful attention to the studies and statements that fail to support neonatal circumcision and wouldn't think of letting his son be altered.

As far as I am concerned, circumcision is an elective cosmetic procedure being routinely performed on individuals who are incapable of giving consent. Although they can not communicate the extent, and do not remember years later, circumcision causes infants stress and at least some degree of pain. And although the complications are infrequent, it is by no means clear that the benefits outweigh the risks. Therefore, I would not, as a doctor, recommend neonatal circumcision to my patients, I would not perform neonatal circumcisions, and my sons, if I have any, will not be circumcised. That said, I understand that many people have and will continue to choose circumcision with the best of intentions. I only hope that parents who have yet to make those decisions will do so with an open mind and as true an understanding of the facts as is possible.

Monday, May 24, 2010

Single Motherhood: Dan Quayle vs. Murphy Brown 18 Years Later

This past week marked what would have been the 18th birthday of Avery Brown, the son born to fictional single mother, Murphy Brown, on the sitcom of the same name. Days after the episode featuring the birth aired, then Vice President Dan Quayle mentioned the show in a speech he gave in response to L.A. riots, regarding the "poverty of values" in America. "It doesn't help matters," Quayle said, "when primetime TV has Murphy Brown, a character who supposedly epitomizes today's intelligent, highly paid professional woman, mocking the importance of fathers, by bearing a child alone, and calling it just another 'lifestyle choice'."

Conservatives who supported Quayle's statement will cite statistics about the less favorable outcomes for children from single-parent homes. Such children are more likely to live in poverty, to become teen parents, to run away from home, to suffer from depression, more likely to end up in prison, etc., etc., etc. However, what the individuals quoting these statistics routinely fail to do is distinguish between correlation and causation. I have no doubt that these correlations are sound. But, I would question whether the fact of having a single parent is the primary cause, independent of other factors, of these children's problems.

In the same breath that he criticized Murphy Brown, Dan Quayle described her as an, "intelligent, highly paid professional woman." Such a woman, in my mind, is precisely the person most likely to succeed at single parenting. So what, precisely, was her crime? Quayle says that she "chooses" to raise a child without a father. But Murphy Brown, like many real women, only chooses to raise her child without a father when the father has expressed his disinterest in being a parent. And what precisely would Quayle have had Murphy Brown do if he'd been writing the script? Presumably, 42-year old Murphy Brown would have been abstinent and therefore never gotten pregnant. Because, of course, Quayle can't have meant to imply that she should have aborted the baby rather than subjecting it to the trauma of growing up without a father. Quayle's speech, given in response to the L.A. riots, could not have included a less relevant example. The delinquents rioting in L.A. didn't come from wealthy homes which merely lacked father figures. They came, more likely, from poor homes, in poor neighborhoods, many born to uneducated, teenage mothers and, yes, on top of all that, they may have grown up without the benefit of a father.

To be fair, I do agree with Quayle that, all other things being equal, children are better off with two parents. However, all other things are rarely equal. And I think that Murphy Brown, despite not having a father for her child, was more than unusually prepared to provide a safe, stable and comfortable home for a child. At 42, and unmarried, her accidental pregnancy represented her first, and probably last, chance at motherhood. If we all let an inability to provide the absolute ideal situation to our children prevent us from having them, we'd none of us have any children at all. I have always known that I want to have children some day. I hope that I have a husband to be a father to those children but I won't let the lack of one stop me.

Dan Quayle and others were and are bemoaning the loss of traditional family values in America. They long for the days when all families were cookie-cutter units of a father, a mother and two perfect little well-adjusted children. The only problem is that, while this happy traditional family may have existed for some, it was a facade for many others. How many homosexual men married women and had children because they believed that was their only option and what kind of life was that for their wives? And for their children when the truth eventually came out? How many women put up with physically abusive husbands because divorce and single motherhood were unacceptable alternatives? How many talented, intelligent women were stay-at-home mothers despite longing to pursue careers and how many women never had children, despite longing for them, simply because they were never fortunate enough to marry? I think a family with a mother, a father and their well-adjusted, biological children, is a perfectly wonderful thing, and more or less represents the family that I came from. But to relentlessly pursue such a family as the only acceptable incarnation of family is foolish. Dan Quayle's attack on Murphy Brown was a blind attack that unnecessarily demonizes a subset of our population that are neither inherently good, nor inherently bad. Being a single parent is not just another "lifestyle choice". It's often not a choice at all.