Science Vs - Circumcision: Why Are We Doing This?

Episode Date: May 31, 2018

This week, we’re entering the foreskin firestorm. We’re asking: what are the risks of circumcision? And are there any medical benefits? To find out we talk to pediatric urologist Andrew Freedman, HIV researcher Godfrey Kigozi, and sex researcher Caroline Pukall. Check out the full transcript here: http://bit.ly/38leLWD Selected readings: The American Academy of Pediatrics technical report, which Andrew helped writeA thoughtful opinion piece from AndrewThe trial in Uganda that Godfrey co-authoredCaroline’s team’s penis-poking studyAnother paper from Caroline’s team on how men feel about their circumcisions Credits:  This episode has been produced by Rose Rimler, with help from Wendy Zukerman, along with Shruti Ravindran and Meryl Horn. Our senior producer is Kaitlyn Sawrey. We’re edited by Blythe Terrell. Additional editing help from Caitlin Kenney. Extra thanks to Soraya Shockley and Saidu Tejan-Thomas. Fact checking by Michelle Harris. Mix and sound design by Emma Munger. Music written by Bobby Lord and Emma Munger. Recording assistance from Gideon Brower, Ryan Delaney, Tom Wayne Harris, and Bahizi Ignatius. For this episode, we also spoke to Dr. Jenn Bossio, Dr. Aaron Tobian, and a bunch of folks at the CDC. Thank you so much. A special thanks to the parents and circumcised men who spoke with us for this story, as well as Frank Lopez, the Zukerman Family, and Joseph Lavelle Wilson. Learn more about your ad choices. Visit podcastchoices.com/adchoices

Hi, I'm Wendy Zuckerman, and you're listening to Science Versus from Gimlet Media. This is the show where we pit facts against foreskins. On today's show, circumcisions. To snip or not to snip? So how many circumcisions do you reckon you've performed? That's a good question. I think we could say more than a thousand. That's a lot question. I think we could say more than 1,000. That's a lot of willies.

Well, yeah. And the man trimming all those willies is Dr Andrew Friedman, a paediatric urologist at Sata Sinai Medical Centre in Los Angeles. And when it comes to circumcisions, Andrew has heard it all. He's heard from anxious parents who don't know what to do, grown men who wish they still had their foreskins, and even teens struggling with their bodies. He told us about this one teenager who came to him asking to get cut

because the other guys at school were teasing him for being uncircumcised. And Andrew was like, dude, it's not about the foreskin. They're teasing you. They're not going to stop teasing you if you have a circumcision. Did you really tell him that? Yeah, because I do believe that. And he was the kind of kid who's kind of an awkward kid, a little socially awkward. I mean, like, he's the kid who's going to get teased. And it's unfortunate, but he didn't need to change his body. It wasn't like the kids were going to say, oh, wow, now you're a really cool guy because now your penis looks like my penis. Come over to my house and we'll play football, you know? It's just, life doesn't work that way.

Okay, so Andrew doesn't think a circumcision will save you from bullies. And he's spent a lot of time thinking about this. Several years ago, Andrew was asked to help write a review for the American Academy of Pediatrics, weighing up the pros and cons of circumcisions. And some people think there are a lot of cons. In fact, there's a group of people called intactivists. And they say it's better to leave the penis as it is. In other words, intact. They argue that this surgery is totally unnecessary and it's cruel.

After all, you're taking a healthy baby and then cutting off a part of them. People wrap up a lot with their penis. And I have received thoughtful letters from adult men who feel like something was taken away from them and are really angry. So, do these intactivists have a point? And if you're a parent trying to make this decision for your baby, what are you supposed to make of all this? To find out, we are entering the foreskin firestorm ourselves

and asking... One, what are the the foreskin firestorm ourselves and asking... One, what are the risks of getting a circumcision? Could it hurt the baby? Two, what are the benefits? Can it prevent infections like UTIs or more serious stuff like HIV? And three, as weird as it is to think about your baby growing up and having sex, we have to ask, could this affect his sex life? And yes, there are religious and ethical questions about circumcision.

But I'm a science journalist, not a rabbi. So today, we're focusing on the scientific questions. Because when it comes to circumcisions, there are lots of willies. Well, yeah. Butisions, there are lots of willies. Well, yeah. But then there's science. Science vs. Circumcision is coming up just after the break. Bumble knows it's hard to start conversations. Hey. No, too basic.

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But in the United States, circumcisions didn't become widespread until around the turn of the 20th century, where some doctors began to promote it as a sort of cure-all for all kinds of health problems. They even said it would stop boys from masturbating. But where there's a willy, there's a way. By the 1970s, though, more and more people started questioning, why are we doing this?

And today, fewer and fewer parents are choosing this for their kids. According to the most recent stats from the Centers for Disease Control, around 40% of baby boys born in the US didn't get circumcised. And in some parts of the country, intact boys are actually in the majority. So, did these kids dodge a bullet? Our first question for today, what are the risks of this surgery? Because lopping off a baby's foreskin sounds pretty scary. Andrew, our pediatric urologist, told us that one common device you can use... Sort of looks like a cigar cutter. Yeah, a cigar cutter is how it works. The foreskin is separated

from the head of the penis, pulled forward. And then you clamp it down and you basically just cut straight across. The way that circumcisions are done with this, like, cigar-cutting tool, like, you would think that, like, a lot could go wrong often. You know, it seems like there's, like, a little penis and a little foreskin and then you have a sharp knife near it all. Can you cut off the penis? OK. Having been in practice for 20 years,

I've seen this three times, OK, in 20 years. And in all of those cases, the penis wasn't lopped off. It had just been clipped a little. Have you, did you, did you do it those three times? No, no, no, no, no, no, no, no. Andrew says he was called in to fix these mistakes. And he says that these cases are, of course, awful. But they're also very uncommon.

It's a bad thing, it shouldn't happen. But I'll acknowledge it happens, but it's very, very rare. And the data backs up Andrew. A recent paper looked at almost 1.5 million circumcisions and found three cases of clipped penises. There are other risks, like bleeding and infections, but overall the risk of a serious complication is less than half a percent. Andrew does acknowledge though that this isn't fun for babies.

Is it painful for a baby to get a circumcision? Yes, it is painful. People just need to be honest about this. It's painful. Andrew says the pain can be managed with a local anaesthetic. So for the most part, it's thought to not be a big deal. Conclusion. In terms of the immediate risks for your baby boy, a circumcision can hurt, but the serious stuff is extremely rare. Still, why risk it at all? What are the potential benefits of cutting off

the foreskin? Well, that brings us to our second question. Can circumcisions reduce the risk of getting an infection? With the foreskin on, there's this idea that the flappy bit makes a nice home for the gunk in your junk. Get rid of the flappy bit, get rid of the gunk. In truth, it's more complicated. It's not like it's necessarily dirty down there, but getting a circumcision can actually protect you from some infections. And that's partly because the foreskin can kind of shuffle in bacteria and viruses. The first time this might matter is when a baby is really young. Having a foreskin makes them more likely to get a urinary tract infection. And it is a real effect. Kids with foreskin had about an 8 to 10 times higher risk

of getting a urinary tract infection in their first year of life. UTIs can be painful for the baby, and in the worst-case scenario, the infection can spread to other parts of the body. Andrew told us, though, that these infections don't happen very often. Even if you have a foreskin, only about 1% of intact babies will get these infections. Another way to wrap your head around these stats is to ask, how many circumcisions do you have to do to stop one willy

getting one urinary tract infection? You have to do like 100 circumcisions to prevent that one infection. That's a lot of foreskins being sacrificed to the god of UTIs. Yeah, so it meant that you had to do an awful lot of circumcisions to prevent every infection. And maybe the god of UTIs doesn't deserve our foreskins because these infections usually aren't that scary and healthy kids can be treated and recover quickly. But what about infections that are a lot more serious? So when these babies grow up and start having sex, can circumcisions protect them from sexually transmitted diseases

like HIV? We talked through this with another doctor, Godfrey Chigozi. Godfrey is the Director of Research at Rakai Health Sciences Program in Uganda, and he's been studying HIV and circumcisions for more than a decade. Now, talking to men about their penises was something that Godfrey never expected he would do. But now, he does it all the time.

Yes, and sometimes I joke with them and say that I have a machine that can scan you to see if you're circumcised. I'm joking. Godfrey's path to studying circumcision started back in the 1990s, when HIV was spreading across Uganda. And it was really scary. Around one in ten adults in the country had the virus. One in ten. Oh, it was a terrible feeling

because there was no medication that could help at all, and we really felt very helpless, and it was so bad. It was so bad. Medicines to treat HIV did exist, but they weren't widely available in Uganda, and scientists were desperately searching for solutions. Godfrey remembers this one day in the midst of the crisis, when he was in a boardroom and another researcher said,

hey, we're finding this weird thing. Men who have a circumcision seem to have a lower risk of getting HIV. And then the researcher asked, so to stop this disease from spreading, should we start giving out circumcisions? And of course everybody in the boardroom laughed because everybody thought he was joking. And why did you think it was a joke?

It sounded weird a bit at the start. Of course if there was anything that was easier to do, we would have taken that. And the reason that Godfrey would have gone for anything else was because he knew this was going to be a really hard sell. Testing the idea would mean convincing people, grown men, to get circumcisions. But Godfrey and his team must be pretty persuasive

because they ended up recruiting more than 2,000 men to get circumcised. Then they followed them for two years, comparing them to a group of men who weren't circumcised. And in 2007, they published their results. Men who were circumcised actually had more than 50% reduction in chances of acquiring HIV. More than 50% reduction in chances of acquiring HIV. More than 50%? Yes.

And what did you feel? Like, what were you thinking at that time when you got those results? Ah, my God. I was feeling like, this is it. The results were so impressive that researchers stopped the trial early because the data was so clear. Circumcisions could reduce a man's risk of getting HIV. At around the same time,

two other trials in Kenya and South Africa found the same thing. And many public health researchers around the world got really excited about Godfrey's work and the other trials. In fact, the results of this work caught the attention of many US doctors, like our own urologist, Andrew. So the HIV is probably, from a world health perspective, the most viable benefit to be derived from circumcision. But for Andrew, this research on HIV in Uganda doesn't give him a clear answer for parents in the US

who want to know whether they should circumcise their kid or not. The question is, how does that work out in the US experience? For a child having a circumcision today to prevent HIV, it's hard to tell you, like, what, you know, is that, in terms of saving lives, is it worth it? Because, on average, in the US, many people aren't that likely to have sex with someone with HIV. And that means your circumcision has less of an opportunity

to come to the rescue. This isn't true for everyone, though. According to data from the CDC, rates of HIV in the US are higher in certain communities, like men who have sex with men, which could mean a circumcision is more likely to protect you. But when it comes to men who have sex with men, things get tricky. Because here's the surprising thing. It's unclear whether circumcisions play an important role in reducing HIV infections amongst gay men. The majority of the really good studies that we have are in straight men. So that's HIV. And what

about other sexually transmitted infections? Well, circumcisions have also been shown to help with genital herpes and HPV. It cuts the risk of having those diseases by roughly 30%. Conclusion. When it comes to infections, circumcisions do reduce the risk of UTIs in babies and they can reduce the risk of some sexually transmitted infections like HIV, herpes and HPV. So, that's infections.

But after the break, we change positions and find out whether circumcisions can mess up your sex life. Can snipping off the foreskin change the sensitivity of your penis? That's coming up after the break. Welcome back. So, circumcisions, they have some benefits. They reduce your risk of catching some infections, including sexually transmitted ones, like HIV. But now we're going to look at this idea

that a circumcision could make your sex life worse. Because for most people with penises, this organ plays a really important role in having good sex. And a circumcision is literally removing a part of the penis. So how could it not affect things down there? We asked a scientist who really knows her way around a penis. Hi there. This is Carolyn Pucall, a professor at Queen's University in Ontario, Canada, where she runs a lab that studies sex. And from early on, it was pretty clear that Carolyn was going to grow up to be a sex researcher. When I was in high school, I sort of became the person in the group that everyone would come to to talk and get advice from. And eventually it became sort of this kind of like, you know, let's go to Caroline and ask her about sex. She seems to know a few things.

And as Carolyn grew up and started her career, an idea kept coming up that circumcisions obviously made sex worse for people with penises. The claim was that the skin at the tip of the penis, called the glands, hardens a bit once there's no foreskin to protect it. Yeah, and I mean, it just makes sense, right? The exposed glands penis is going to be rubbing against underwear. It's exposed to all of these like different kinds of friction, like in jeans and pants. It makes sense that that skin would harden and there would be lower sensitivity in men who did not have a foreskin. It made sense, but Caroline didn't just want to assume it was true. People were like, well, you know, Caroline.

I was like, I actually don't know that. And I thought to myself, if I ever get my own research lab, I would like to examine this. Carolyn, of course, now has her own research lab. So, she thought, time to get to the bottom of this. Here's what Carolyn and her colleagues did. They got about 60 men, half circumcised at birth and the other half still intact.

And then the fun, I mean, the experiment, could begin. Carolyn and her team had a variety of ways of measuring whether the circumcised penis was actually less sensitive than the uncircumcised. One involved prodding penises with these poking devices. They're short, they're thick, and it's like bristles on a brush. Then she pushed the bristles into the head of their penises. So it would be like, yes, I feel that.

Is it painful or not? No, it isn't. We'd go to the next one. Is it painful or not? Yes, it is. And that would be their pain threshold. And did you get, were men like, ouch, ouch, ouch, ouch? Like, how?

Some men were. It has a sort of an unpleasant kind of sharp, pricky kind of feeling to it. Hey, you can't do a penis sensitivity study without poking a few penises. And here's what Carolyn's team learned. We found that the penises overall of intact and circumcised men were not significantly different in terms of tactile pain,

which was actually very, very interesting. Oh, wow. So the head of the penis, that bit that spent all those years rubbing against underwear and whatnot, it was just as sensitive in the circumcised men as it was in those who still had their foreskins. We were really surprised. We were really, really surprised. And although this was just one study, we did find two other research papers that saw the same thing. No difference in the penis's sensitivity.

In fact, the only study that we did find that reported a difference here was funded by a group that's now called Genital Autonomy America. Yeah, Genital Autonomy America, which is a group fighting for an independent, autonomous nation of penises and vaginas. No, of course not. It's an anti-circumcision group. But that's not the end of the story,

because Carolyn and her team also tested the foreskins of the intact men, and she found that the skin there really did respond to a prod. Or as Carolyn says. So the foreskin in and of itself was exceptionally sensitive to touch. Aha, so what does this then tell us about whether circumcision makes it less fun to have sex? Well, it certainly something is amiss. Through circumcision, the foreskin is being removed and it is a sensitive part of the penis. And this really sounds like circumcisions might make sex worse. But Carolyn says, hold your horses.

Whether that translates to sexual sensation remains to be really demonstrated through research. Carolyn's experiment was such an unsexy situation. The men were in a lab, they were not erect, and they were not having sex. And sex, Carolyn says, is about so much more than sensitivity you can measure with probes. Orgasms include more than just the genitals that are involved, and so it really depends on novelty,

it depends on one's state of mind, it depends on comfort with the partner. one's state of mind. It depends on comfort with the partner. It's more of a sort of a whole body experience. And it's not like the foreskin is sensitive in a way that you can't even imagine. Carolyn found it was about as sensitive as another part of the body, the forearm. So if you flip your forearm kind of over, so you're looking at like the inside of it, we test about four inches below the wrist. And that area is just a very sensitive part of the body. Well, I've been having sex wrong, haven't I?

We all have been. Which really speaks, I think, to, you know, sort of including the whole body in terms of sexual activity. Absolutely. It's like, don't ignore the forearm, go for it. So because sex doesn't boil down to this body part or that body part, Carolyn's lab study can only take us so far. Another way to look at how circumcisions affect sex lives is to ask grown men who have gotten circumcisions to describe their experiences with sex before and after. And researchers have done this.

And on the whole, these men report that sex doesn't change much, but everyone's experience is a little different. And that made us really curious to talk to some of these men who had had circumcisions as adults. So our producer, Rose Rimler, called up a bunch of them. I guess, uh, tell me about your penis. OK. Something I noticed after I had it chopped off

was it was just constantly brushing up against things and it was driving me crazy. The head is just as sensitive as everything else. It still feels great, but, um, you're missing that extra surface area. Honestly, if a fairy met with me in the woods now and offered me to give me the foreskin back, I'd decline because it's been so nice.

It's healed and it's actually totally fine. I think it's pretty much just as good either way. The foreskin isn't magic, in other words. Yeah, yeah, it was super cool. It was great to have it. I thought mine looked all right, you know, but it's no great loss. To bring this to a head,

a recent review paper found that there wasn't hard evidence to support the idea that circumcisions make sex worse for men. Certainly, millions of circumcised men around the world still really, really enjoy sex. That's not the case for everyone, though. During Carolyn's research on circumcisions, she found a group of people who have real issues with their circumcised penises. I did come across some people who actually seemed very traumatised by their lack of foreskin. Some of them told Carolyn that they were upset

that something important to them had been removed from their body and they didn't have any choice in it. Some blamed their long-lost foreskins for a lack of sexual confidence or for their body issues. So when you put it all together, do you think that being intact increases your chance of having better sex? Well, I think that it doesn't usually matter, but when it matters, it matters a lot. So most people with penises don't care about their circumcision status. They don't spend a lot of time thinking about it.

But if their circumcision status does matter to them, it is part of their identity. And it can affect their sexual pleasure in a way that is damaging. Conclusion. As best as science can tell, a circumcision does not make a penis less sensitive and it's unlikely to affect a man's sex life in a big way. Still though, for a small group of men, they take their circumcisions really hard and then it does affect their sex life. So when it comes to circumcisions, do they stack up? One, are there risks to this surgery?

Well, it can be painful and there can be serious complications, but they are very rare. Two, does it reduce your risk of infections? Yes. For babies, it cuts down the risk of UTIs, but that's a rare disease anyway. And when that baby grows up and starts getting laid, it can reduce their risk of HIV, HPV and herpes.

Three, when it comes to men's sex life, does it put a damper on things? It's unlikely getting snipped plays a huge role in sexual pleasure for most men. So what are we to make of this? Well, when Andrew, our circumcision guru, and his team at the American Academy of Pediatrics wrapped up their review, what did they say? We felt that the benefits outweighed the risk

enough that people who want it should be allowed to have it, should have access to it. But it doesn't have enough benefit to say everybody ought to have it. To cut to the chase? To be fair, the benefits are very, very modest. The risks are very, very modest. So to Andrew, either choice is valid. And when he had to make the decision, it actually wasn't about the medical benefits. So I have a son. My son is 14. When he was little, did you decide to give him a circumcision?

Yes, I did decide to do a circumcision. At the time I did it, I didn't feel like I was doing it as a doctor. I was doing it as a religious ceremony. I'm a practicing Jew, and in our traditions, we do the circumcision on the eighth day. And how did you feel as a scientist that you were making this big decision for your son based on religion? You're not one thing. So I'm not a scientist 24-7. I mean, like all people, we're complicated. And that's why you have to kind of respect that it's a messy decision. I mean, we want to try to make this a black and white decision where you just, you know,

you punch a bunch of numbers into a computer and you spit out the right answer. But it's not that way. It's a messy decision. Andrew says Americans should just get used to the idea that there will be different kinds of penises. In fact, he envisions a world, a better world, a beautiful world, where every sort of penis has its place in the rainbow. Why do all penises have to look alike? Why can't some people do one thing and some people do another and let families do what they feel is best for them? Someday.

Maybe. That's Science vs. Circumcisions. Great! Those are our only questions. That's science versus circumcisions. Great. Those are our only questions. Is there anything you wanted to add? To anyone out there, if you have any comments or concerns about anything I've said, please send your email to science versus... Sorry, there's something wrong with the connection here

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That's scienceversus, science vs, dot show slash survey. Thank you. This episode has been produced by Rose Rimler with help from me, Wendy Zuckerman, along with Truti Ravindran and Meryl Horne. Our senior producer is Caitlin Sorey. We're edited by Blythe Terrell, additional editing help from Caitlin Kenny. An extra thanks to Soraya Shockley and Saeed Tajan Thomas. Fact-checking by Michelle Harris,

mix and sound design by Emma Munger, music written by Bobby Lord and Emma Munger. Recording assistance from Gideon Brower, Ryan Delaney, Tom Wayne Harris and Bahizi Ignatius. For this episode, we also spoke to Dr Jen Bossio, Dr Aaron Tobian and a bunch of folks at the CDC. Thank you so much. A special thanks to the parents and circumcised men

who spoke with us for this story, as well as Frank Lopez and to all my family and Joseph Lavelle-Wilson. We're off next week, but we'll be back in two weeks and then we're tackling Lyme disease. Should you be afraid of it? Physicians don't want, they don't want to go near these patients. The patients are regarded as lepers. They don't want to go near them with a 10-foot pole.

I'm Wendy Zuckerman back to you next time