What are all of your thoughts on Intactivism as a potential Effective Altruist cause area? Intactivism, for those who are unfamiliar, is the movement to abolish neonatal male circumcision. In his lecture Sex and Circumcision: An American Love Story, Eric Clopper goes deep into detail discussing the origins of male circumcision, namely that it was designed to damage men’s sexuality, and the common arguments people use in favor of it, such as whether it prevents STDs. He also discusses the fallacies and flawed science often used to defend the practice. Ryan McAllister’s lecture Child Circumcision: An Elephant in the Hospital discusses many similar topics.
Intactivism seems to satisfy all of the 80,000 Hours criteria for cause prioritization, in the sense that the issue of reducing neonatal circumcision is important, tractable, and uncrowded.
Intactivism is important. In the United States and Israel, the majority of the male population has been circumcised at birth. In the 20th century alone, over 120 million circumcisions were performed in the United States, most of which on non-consenting infants, with a circumcision happening every 17 seconds at its peak during 1955-1965. The procedure itself is extremely traumatic, and greatly reduces sexual pleasure for both sexes. In his book Circumcision: The Hidden Trauma, Dr. Ronald Goldman, PhD argues that circumcised men may also be at increased risk for mental illness. In the United States, only about 45% of physicians that perform circumcisions use any form of anesthesia. There are also a number of complications that can result from the procedure, such as skin bridges, infections of the circumcision wound, and amputation neuromas. Circumcision is also practiced among Muslims, Africans, and South Koreans, but is typically performed relatively later in life, rather than in infancy. Circumcision is also multi-generational in scope, with the practice existing for millennia in many cultures. It has been practiced in the United States since the late 1800s, and will only continue if nothing is done about it.
Intactivism is tractable. In the Anglosphere countries besides the United States, circumcision was once widespread, but has since declined precipitously. Routine circumcision in Australia reached its zenith in the 1950s with a rate above 80%, but has since declined to a rate of less than 20% for children born today. In Canada, the circumcision rate has declined from 48% in 1970, to a newborn circumcision rate of 31.9% in 2009. In the United Kingdom, the proportion of English boys who were circumcised fell from 35% in the early 1930s to 6.5% by the mid-1980s. South Korea has also experienced a significant decline in their national circumcision rate, declining from 86.3% for males aged 14-29 in 2002, to 75.8% a decade later. Circumcision rates in the Western United States have also declined, with roughly two thirds of boys in Western states were circumcised in 1979, declining to only 40% in 2010. In the US, states where neonatal circumcisions are not covered by Medicaid have significantly lower circumcision rates compared to states where it does. Thus, efforts to end Medicaid coverage for circumcisions may prove highly effective at reducing the circumcision rate in the US. There is also a company called Foregen, which is doing research in regenerative medicine in order to regenerate the foreskin so that formerly circumcised men can once again have complete penises.
Intactivism is uncrowded. Almost all of the effort put into ending genital mutilation is focused on female genital mutilation, rather than male genital mutilation. Circumcision generally seems to attract little media attention, and seems to be discussed infrequently.
One of the common arguments in favor of male circumcision is that it prevents STDs. The evidence for this seems to be questionable at best. Europe has a significantly lower rate of HIV infection than the US, despite having a population that is almost entirely genitally intact. The AIDS incidence rate for men in the United States is fourfold that of the incidence rate of Switzerland, the European country with the highest rate. There were a number of African studies that supposedly provided evidence that circumcision reduces the risk of HIV in Africa, but these studies had a number of methodological flaws. In Africa, there is a possibility that mass adoption of circumcision may actually increase HIV rates, due to factors such as risk compensation and the circumcisions being performed in unsanitary conditions. In any case, there is little reason why circumcisions should be performed on non-consenting infants rather than on consenting adults, since infants and children are generally not at risk for STDs.
As a side note, there is some debate as to whether infants are sentient. Since there is some evidence that circumcised infants may experience levels of pain consistent with torture, this issue is of particular importance. If infants are not sentient, they are incapable of experiencing suffering by default. However, this is balanced by the fact that there is still a >0% chance that infants are sentient, and that this is an issue that affects tens of millions of people.
Discuss.
Meta: I think we should have more posts like this in that I want to see more discussion of different cause areas. However, I spent a lot of time in a research rabbit hole after reading this, and I wound up being disappointed with the execution of the post. So: while the concept of the post was good, and I think the author's intentions were good, I'm going to be honest in my criticism.
I appreciate the breakdown of importance, tractability, and crowdedness here, but I don't think this post uses scout mindset; it's written to persuade, and leaves out a lot of contradictory evidence while overstating the strength of other evidence.
In the end, I decided to downvote; once I'd spent ~90 minutes reading evidence from both sides, I found that this post linked to weaker resources than most others I found, and with a strong bias that made it hard to trust anything I was reading.
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Most things have pros and cons. There will occasionally be cases where every argument and consideration lines up on one side of a question, but they are rare, while confirmation bias is common and produces the same impression. (See also "surprising and suspicious convergence".)
I checked a couple of links, and quickly found a few misleading statements:
The linked study refers to the circumcision of adult males, which seems extremely rare and isn't the target of intactivism. I was expecting to see a comparison of men who were circumcised as babies and men who weren't; the use of this study makes me wonder whether the study I "expected" actually exists, and if so, what the results were. (I then found this literature review, which seems like reasonably strong evidence of weak-to-nonexistent differences in pleasure.)
11 million men in this dataset chose to become circumcised, leaving 110 million infants. There are 3.15 billion seconds in a century, so an infant circumcision happened roughly every 29 seconds. This is still very bad if circumcision is bad, but the division mistake leaves me questioning everything else just a bit more.
Meanwhile, the discussion of HIV differences between the U.S. and Europe left me cold. There are many, many differences between those two parts of the world — sexual mores, sex education, demographics, access to preventative care, prevalence of high-risk clusters... even if circumcision did reduce HIV transmission rates (I acknowledge that the positive evidence there has sometimes been overstated), those other factors could easily overwhelm that single protective element.
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I'm disinclined to force permanent surgery on infants without strong evidence of benefit, and I'm dubious that current evidence is strong enough. I'm also curious about the difference between American and European medical norms. Overall, I'm open to the idea that male circumcision is net-negative and that reducing rates around the world is a reasonable "normal" charitable cause. And I respect the views of people who don't want their tax dollars to pay for a nonconsensual surgery with uncertain benefits.
But the quality of intactivist argumentation that I've seen (linked from this post and elsewhere) is... mixed. And given that circumcision has clear health benefits (UTI risk, penile cancer risk) and remains the subject of active debate, I find it hard to imagine this cause area stacking up against something like malaria prevention.
I did link to a number of resources that address the arguments from circumcision proponents though, such as Eric Clopper’s lecture. I also mentioned the possibility of infants not being sentient, which would weaken the case for it as a cause area.
Keep in mind that the circumcision proponents may also have confirmation bias. Since circumcision is a highly profitable industry for hospitals, there may be economic incentives for medical/academic institutions to be biased in favor of it. For example, the AAP Circumcision Task Force 2012 operated as a way of preserving third party payment. The task force also apparently did not have a single member with an intact foreskin, and thus did not have informed opinions on the foreskin and its functions. Some circumcised men may also be emotionally invested in defending circumcision for cultural reasons, or since they may be uncomfortable with the possibility that they are missing out on the increased sexual satisfaction they may have had if their foreskins had remained intact.
Regarding your literature review, I found this article written in direct response to it. It’s virtually impossible to study the differences in subjective sexual pleasure between men who were circumcised as infants compared to those who remain intact as adults, simply because two individuals cannot access each other's memories and subjective experiences in order to make an accurate comparison. It’s far easier to study men who were circumcised as adults, simply because they remember being intact and can more easily make a comparison. Eric Clopper also talks extensively about many of the methodological flaws in many of the studies used to defend circumcision in his lecture. Regarding the author of your meta-analysis, Brian J. Morris, IntactiWiki has quite a lot to say about him.
If you believe that there is no significant difference in sexual pleasure between intact men and men who were circumcised as infants, that would seem to imply that there is some mechanism by which the penis/brain compensates for the lost nerve endings and keratinization of the glans. Since thousands of nerve endings are physically removed, that would seem to imply that either the remaining nerve endings somehow become more sensitive, or that new nerve endings regrow to make up for those that are lost. Do you have any strong evidence that this happens? Alternatively, what could happen is that the nerves simply atrophy, or that the severed nerve endings could grow into amputation neuromas instead of new pleasurable nerve endings.
I probably could have worded that better, I apologize. I edited the post to state it a bit more clearly. The statistic I cited was the circumcision rate at its peak, not the average circumcision rate throughout the entire century. Here’s the direct quote from the article I linked:
During 20th century, more than 120 million foreskins were severed from American penises, more than in any other country in the world. At the height of the circumcision frenzy, a foreskin was being sundered, and a penis crippled, every 17 seconds.
The peak in the number of circumcisions performed per year according to the article was during 1955-1965. Here's also some data on the number of births per year in the US, apparently peaking during 1957.
From the article: The annual number of circumcisions was highest between 1955 and 1965. During that decade, 1.8 million males were circumcised every year -- almost 5,000 every day.
You could make the same argument about Africa. One argument I’ve heard from circumcision proponents is that northern/central Africa (which has higher circumcision rates) has lower HIV rates than southern Africa, and this is evidence that circumcision reduces HIV transmission. Yet there are also many, many cultural differences between different parts of Africa. For example, the Sahel is predominantly Muslim whereas southern Africa is predominantly Christian. Lesotho and Eswatini, the 2 African countries with the highest HIV rates in the world, have cultures with a high rate of multiple concurrent partnerships. In Lesotho, there is a practice known as bonyatsi, which involves people of both genders maintaining many sexual partners, even after marriage. In Eswatini, there is also a traditional culture that discourages safe sexual practices.
There are also other parts of the world besides Europe that don’t circumcise and have low rates of HIV. Latin America, India, and East Asia all have fairly low rates of HIV infection despite having populations that are mostly intact. India, for example, has an adult HIV prevalence rate of only 0.2%, despite being far poorer than the US or Europe. The US, by comparison, has an HIV prevalence rate of 0.3%. China is even lower, at 0.09%.
If you believe that circumcision has significant health benefits, you still have to explain why the foreskin evolved in the first place. If the foreskin was net harmful, evolution probably would have gotten rid of the foreskin long ago. Yet almost every species of mammal has some form of foreskin or penile sheath. Aposthia exists at a low rate within the population, but any genetic predisposition towards it has evidently not undergone any degree of positive selection pressure. If you accept evolution, this seems to imply that the foreskin has historically been a net evolutionary benefit, and any health effects resulting from it are insignificant.
The argument about penile cancer is just grasping at straws. Eric Clopper actually mentioned penile cancer risk and UTIs in his lecture. Penile cancer is a rare cancer in the first place, and almost entirely affects old men. Even if you believe reduced risk of penile cause area is a significant benefit of circumcision, it involves performing tens of thousands of circumcisions to prevent a single case of penile cancer. If you still believe that reducing the rate of an already rare cancer is a legitimate reason for amputating a body part, you should also advocate for removing many other body parts if you want to be consistent, such as removing girls’ breast buds to prevent breast cancer, amputating the toes to prevent toe cancer, etc.
On the topic of UTI risk, UTIs can sometimes result from forced retraction of the foreskin. This can easily be prevented by not retracting the foreskin before the balano-preputial lamina has dissolved. The lifetime UTI risk for intact men appears to be only very slightly higher compared to circumcised men, with the risks being 1.29% and 1.27%, respectively.
For other potential EA causes like malaria prevention, these causes may also have significant drawbacks and unintended consequences. For example, Nassim Taleb believes that the Gates Foundation is repeating the errors of Mao Zedong. Malaria nets may also often go unused, or could also cause local net manufacturers to go out of business. Africans may also view malaria as a minor ailment, similar to how we view the cold of flu.
Thanks for an interesting new cause area! I found myself feeling uneasy about a potential controversy here, so here are my 2 cents on the matter.
The large elephant that remains unaddressed in this analysis is that circumcision is done in large part for religious reasons. In Israel at least, any policy or procedural changes toward intactivism are likely very hard and will encounter a lot of resistance.
More broadly, taking actions on causes that are explicitly against other people's moral agenda is risky for the reputation of the people involved or the EA movement if it's done under that name. If this cause does in fact appear promising under further investigation, I recommend whoever might take action on this to consult with CEA.
That said, I think it is very important to figure out the most promising causes and how to do the most good, even if the results might clash with other people's beliefs. So again, thanks for raising and argumenting for a potentially controversial cause.
In the United States, Canada, and South Korea, the vast majority of circumcisions are secular and performed in hospitals. They persist for social reasons, hospitals operating for profit, and because of various health myths, rather than because of religion. Personally, I am circumcised, and my father is an atheist.
As for specific policy changes, I will admit that reducing religious circumcision among Jews and Muslims is much more intractable than reducing secular circumcisions among Americans, and an outright ban is almost impossible. Efforts toward reducing circumcision don’t necessarily have to involve any policy changes at all. Educating people and spreading the word would likely be effective at convincing a significant portion of the population to not circumcise their sons. I think the most realistic policy change that could bring down the circumcision rate in the US is to cease Medicaid/health insurance funding for circumcisions. Something similar already exists in Australia. Circumcision is banned in Australian public hospitals, but parents can still go to private hospitals to have their sons circumcised. Jews, for instance, would still be able to hold a traditional bris ceremony legally, but anyone who wants to circumcise their son would be forced to pay out of pocket for it. It could also potentially save taxpayers a significant amount of money.
For Jews, there’s an alternative to the traditional bris ceremony practiced by a minority of Jews called the brit shalom. For Christians, here is a website I found with information about the Biblical view of circumcision. Historically, virtually no Christians practiced circumcision, and the practice only started becoming a common occurrence among American Christians during the late 1800s.
For more on health impacts you might want to take a look at this Slate Star Codex post which has a decent objective overview, also a good discussion in the comments. The circumcision debate is somewhat fraught; maybe that's an understatement. Regardless I'll be interested to follow the discussion here.
Thanks for sharing a write up of a potential new cause area - I'd love to see more of these and I think yours is really clear.
These two statements on the surface seem contradictory, given I haven't heard of significant activist work on this in Canada, Australia, etc:
"It has been practiced in the United States since the late 1800s, and will only continue if nothing is done about it."
"In the Anglosphere countries besides the United States, circumcision was once widespread, but has since declined precipitously."
I don't know enough about the cultures and internal workings of Australia, Canada, the UK, etc. to give you a good answer for how precisely this shift took place. But the fact of the matter is that something took place in these countries that caused the practice of circumcision to be abandoned en masse.
The point I'm trying to get at is that there's a risk that circumcision won't decline in the US as it has in other countries, and that it will keep being practiced for centuries. The longer circumcision continues, the more culturally entrenched it will get, and the harder it will be to get rid of. Plenty of people who are part of genital cutting cultures defend it because it's "part of their culture". For example, here are some quotes from Andrew Freedman on why he defends circumcision:
"I circumcised him myself on my parents’ kitchen table on the eighth day of his life. But I did it for religious, not medical reasons. I did it because I had 3,000 years of ancestors looking over my shoulder."
"I didn't make any excuses that this was to avoid a UTI, or for medical reasons. My rationale was this: As a Jewish male in a long line of tradition, I didn't want to be the link in a chain that broke."
Thank you very much for writing this up!
- This 2010 paper estimates that over 100 newborn boys die in the US annually from circumcision and related complications.
- Alexithymia, poor recognition of one's emotions, is another condition that may result from circumcision. Paper here. I wonder if the stereotype of American men being out of touch with their emotions is related to this?
- RE sentience: Intact America claims that as adults, some men still remember the experience of being circumcised as infants. Cross-check: some adults still remember being born.
- Some US-based charities that work toward ending infant male circumcision are Doctors Opposing Circumcision, Intact America, and Bloodstained Men. I've donated to Intact America several times; I appreciate that they thought to check who is initiating, and as of recently are focusing on trying to get nurses to stop suggesting the procedure to new moms in the hospital.