Hi questionhaver, I just wanted to make sure that you saw this response as an answer to your question, so I am posting it here as an answer. After I wrote it in reply to a comment below, I realize that it actually did a much better job of answering some of your questions more fully, especially the last few paragraphs which illustrate some interventions that are potentially even more impactful.
First, here are some more detailed discussion on the cost-effectiveness from QALYs (quality adjusted life years) which is a metric that values the quality of a year of life multiplied by number of years (section 1) then a brief section on other interventions (section 2).
Section 1
As I noted above, I think there are highly cost-effective interventions that could prevent one circumcision per dollar or more in expectation.
If we assume this reduces sexual pleasure by 20% [1]and that sexual pleasure accounts for 5% of life happiness [2]for average males we could get a rough Fermi estimate of 5% x 20% = 1% reduction in life satisfaction, and if we very, very crudely say that this is similar to losing 1% of 5O years of QALYs, this would be losing .5 QALYs per circumcision, and preventing one circumcision for one dollar would be 2$ per QALY.
I think malaria nets - Givewell’s perennial top charity - are estimated to be about $50 per QALY, so even estimates that were extremely more conservative, like if an intact foreskin only accounts for 5% of sexual pleasure [3]and sexual pleasure only accounts for 2% of overall life satisfaction, it would still be equally effective as bed nets.
More importantly in my opinion, I think most of the harm of circumcision comes from extremely severe PTSD and trauma suffered in rare cases, as evidenced in the Reddit “circumcision grief” and a few studies, and numerous anecdotal accounts I could give. I think some lives are made negative at a ratio of 10:1 to 1,000:1 negative to positive experiences. I would personally say I am in the 10:1 to 100:1 category, despite having healed my PTSD after about three years of it, most men don’t. I suspect it is extremely unlikely my life will ever become positive without life extension/other trans-humanist technology.
I think it is not unreasonable to estimate that 1 in 10,000 men have their lives made net negative at a 10:1 negative to positive ratio (and/or equivalently, made 1:1 negative to positive ratio for 1 in 1,000 men, or 10% worse for 1 in 100 men.) In fact, I think this is conservative based on what I’ve seen; remember this is an experience of genital mutilation as perceived and experienced from the perspective of these men, I don’t think we would question this in the case of female or intersex genital mutilation, and the extraordinarily severe lifelong PTSD that can result. In fact, my understanding is that infant death, loss of the entire penis, and very severe complications leading to permanent extremely limited sexual capability due to circumcision are, combined, far more common than 1/10,000.
That would mean that there is very, very roughly the equivalent of about 50 QALYs (~average American lifespan) lost per 1000 circumcisions, or about 1 QALY per 20 circumcisions. I think the extreme suffering here should count for significantly more, as I think a prioritarian, suffering-biased ethic is probably correct (extreme suffering should be weighed more heavily than average happiness.) And I think the real numbers are possibly much worse than what I stated, perhaps by a factor of 10 or more. But even on this conservative estimate, at one dollar per circumcision prevented, this would be very roughly $20 per QALY, which is again surpisingly good.
Section 2
I think there may be some hits-based leveraged bets that could be 10X to 100X more effective in expectation;
For example, funding scalable trauma treatment (I was working on this and was quite close to finishing a book, and then next was plainning to create a scalable healing program, but burned out and had to quit, partially due to disability and severe funding constraints.) Currently quality circumcision trauma healing is extremely hard to find, so this would be a huge boon, and since I’ve already completed most of the work this can be completed relatively cheaply.
I think $10,000,000 could double the chances of foreskin regeneration happening soon, or perhaps bring it forward by 10 or 20 years in expectation, and I know people who are actively seeking funding to make this happen. Once the procedure is available this can be self-funding - an estimate based on Aella's research gives a $200+ billion market for foreskin regeneration, another indication of value - and as a cultural phenomenon this could lead to much lower circumcision rates or even speed the banning of it in developed countries.
I know some native activists in sub-Saharan Africa[4] who are fundable for a very, very, very small fraction of what US work costs, making this potentially extremely cost-effective, and it is unfortunately highly under-funded. One obstacle here is that we would need some infrastructure set up to make these activists more fundable and effective.
So, all things considered, I think if we are serious about improving the world, we should not dismiss this out-of-hand and at least do a deeper dive into this to confirm how cost-effective it in fact is. All of these are quite rough estimates, hence why I tried to be conservative, deeper research would be needed to confirm.
*Note I did not count flow-through effects here for most of this, and I think flow-through effects could be quite significant.
Most estimates seem to range between 10% and 90%, [5]and it is notable that there is significant methodological difficulty in objectively measuring differences in pleasure, resulting in significant uncertainty here—although there is high information value in investigating further
I don’t think it’s unreasonable to think that a male with no sexual pleasure has lost at least 5% of his overall happiness on average; of course some males value much higher and some much lower
Despite being 1/3 to 1/2 the skin of the penis, being probably most of the nerve endings and almost all of the fine-touch nerve endings of the penis, in addition to providing several significant sexual functions important for both male pleasure and female comfort and vastly increased masturbatory pleasure
My understanding is that circumcision is not at all cost-effective for fighting AIDS compared to other interventions, even if the studies were accurate, but there are some very severe flaws in the studies and more recent research contradicting that there is any positive effect—although strong caveat that I haven’t looked into this deeply.
Do note sexual sensation/pleasure is different than sexual satisfaction, effects on sexual satisfaction seem to be much smaller (although there is also very similar life satisfaction after couple years between new lottery winners and newly acquired paraplegics—cf. narrative life satisfaction vs. direct hedonic wellbeing
Hi Rowan, thanks for your thoughts on this, and for acknowledging that it violates bodily autonomy and reduces sensation. However, I would respectfully disagree that we should out-of-hand dismiss it as an effective cause area.
Why it could be effective
As I noted above in my first comment on Intaction's health equity campaign (HEC) and Intact Global, I think there are highly cost-effective interventions that could prevent one circumcision per dollar or more in expectation.
If we assume this reduces sexual pleasure by 20% [1]and that sexual pleasure accounts for 5% of life happiness [2]for average males we could get a rough Fermi estimate of 5% x 20% = 1% reduction in life satisfaction, and if we very, very crudely say that this is similar to losing 1% of 5O years of QALYs, this would be losing .5 QALYs per circumcision, and preventing one circumcision for one dollar would be 2$ per QALY.
I think malaria nets - Givewell’s perennial top charity - are estimated to be about $50 per QALY, so even estimates that were extremely more conservative, like if an intact foreskin only accounts for 5% of sexual pleasure [3]and sexual pleasure only accounts for 2% of overall life satisfaction, it would still be equally effective as bed nets.
More importantly in my opinion, I think most of the harm of circumcision comes from extremely severe PTSD and trauma suffered in rare cases, as evidenced in the Reddit “circumcision grief” and a few studies, and numerous anecdotal accounts I could give. I think some lives are made negative at a ratio of 10:1 to 1,000:1 negative to positive experiences. I would personally say I am in the 10:1 to 100:1 category, despite having healed my PTSD after about three years of it, most men don’t. I suspect it is extremely unlikely my life will ever become positive without life extension/other trans-humanist technology.
I think it is not unreasonable to estimate that 1 in 10,000 men have their lives made net negative at a 10:1 negative to positive ratio (and/or equivalently, made 1:1 negative to positive ratio for 1 in 1,000 men, or 10% worse for 1 in 100 men.) In fact, I think this is conservative based on what I’ve seen; remember this is an experience of genital mutilation as perceived and experienced from the perspective of these men, I don’t think we would question this in the case of female or intersex genital mutilation, and the extraordinarily severe lifelong PTSD that can result. In fact, my understanding is that infant death, loss of the entire penis, and very severe complications leading to permanent extremely limited sexual capability due to circumcision are, combined, far more common than 1/10,000.
That would mean that there is very, very roughly the equivalent of about 50 QALYs (~average American lifespan) lost per 1000 circumcisions, or about 1 QALY per 20 circumcisions. I think the extreme suffering here should count for significantly more, as I think a prioritarian, suffering-biased ethic is probably correct (extreme suffering should be weighed more heavily than average happiness.) And I think the real numbers are possibly much worse than what I stated, perhaps by a factor of 10 or more. But even on this conservative estimate, at one dollar per circumcision prevented, this would be very roughly $20 per QALY, which is again surpisingly good.
I think there may be some hits-based leveraged bets that could be 10X to 100X more effective in expectation;
For example, funding scalable trauma treatment (I was working on this and was quite close to finishing a book, and then next was plainning to create a scalable healing program, but burned out and had to quit, partially due to disability and severe funding constraints.) Currently quality circumcision trauma healing is extremely hard to find, so this would be a huge boon, and since I’ve already completed most of the work this can be completed relatively cheaply.
I think $10,000,000 could double the chances of foreskin regeneration happening soon, or perhaps bring it forward by 10 or 20 years in expectation, and I know people who are actively seeking funding to make this happen. Once the procedure is available this can be self-funding - an estimate based on Aella's research gives a $200+ billion market for foreskin regeneration, another indication of value - and as a cultural phenomenon this could lead to much lower circumcision rates or even speed the banning of it in developed countries.
I know some native activists in sub-Saharan Africa[4] who are fundable for a very, very, very small fraction of what US work costs, making this potentially extremely cost-effective, and it is unfortunately highly under-funded. One obstacle here is that we would need some infrastructure set up to make these activists more fundable and effective.
So, all things considered, I think if we are serious about improving the world, we should not dismiss this out-of-hand and at least do a deeper dive into this to confirm how cost-effective it in fact is. All of these are quite rough estimates, hence why I tried to be conservative, deeper research would be needed to confirm.
*Note I did not count flow-through effects here for most of this, and I think flow-through effects could be quite significant.
Most estimates seem to range between 10% and 90%, [5]and it is notable that there is significant methodological difficulty in objectively measuring differences in pleasure, resulting in significant uncertainty here—although there is high information value in investigating further
I don’t think it’s unreasonable to think that a male with no sexual pleasure has lost at least 5% of his overall happiness on average; of course some males value much higher and some much lower
Despite being 1/3 to 1/2 the skin of the penis, being probably most of the nerve endings and almost all of the fine-touch nerve endings of the penis, in addition to providing several significant sexual functions important for both male pleasure and female comfort and vastly increased masturbatory pleasure
My understanding is that circumcision is not at all cost-effective for fighting AIDS compared to other interventions, even if the studies were accurate, but there are some very severe flaws in the studies and more recent research contradicting that there is any positive effect—although strong caveat that I haven’t looked into this deeply.
Do note sexual sensation/pleasure is different than sexual satisfaction, effects on sexual satisfaction seem to be much smaller (although there is also very similar life satisfaction after couple years between new lottery winners and newly acquired paraplegics—cf. narrative life satisfaction vs. direct hedonic wellbeing
Check out the health equity campaign (HEC) put on by Intaction. They’ve prevented circumcision from being added to Medicaid in some states, which is known to significantly reduce rates, so for probably something small, I would guess less than $100,000, I would say in expectation they’ve prevented something like 5,000 circumcisions per year as long as these policies stay in place, which could be for several years or even decades, which could mean as low as $1-$2 per unnecessary circumcision prevented.
Much more importantly, Intaction is now lobbying at the capital, and this is the first time this has happened in US history. It will be much harder to have an impact, but the impact could be much higher if it at all adds momentum to broad public debate on the topic and ultimately to the (at least nonreligious) practice being banned completely in the United States, which could have a serious ripple effect throughout the world considering a lot of nonreligious circumcision that exists in other countries has been due to US cultural and pseudo-medical influence[1].
I would also check out Eric Clopper and his lawsuit in Oregon with his organization Intact Global. Establishing the unfathomably severe harm of the practice with a win in the courts seems quite plausible, especially in Oregon where rates are very low, and there’s no question the practice violates equal protection. This could help lead the way to a state ban, which again could be crucial for momentum toward more state bans and eventually a national conversation and potential ban.
Importantly, I think both of these are taking relatively conservative approaches and not trying to challenge religious circumcision directly which is what defeated the attempted ban in San Francisco. It seems important to protect children of all religions from genital mutilation and not discriminate against Jews and Muslims, however, I don’t think this is a realistic/helpful/cost-effective place to start as claims of anti-semitism end up severely distracting from the real issue of severe and permanent nonconsensual genital modifications performed on children.
I think it’s very clear that circumcision has far more medical harms than benefits if you look at the data, and agree that in the US the practice is best conceptualized as genital mutilation intended to prevent sexual pleasure and punish masturbation, which is where its roots in the the Victorian age in the US and UK originated, with attempts only coming much later to justify it medically.
Absolutely, glad to be of help!
Hi questionhaver, I just wanted to make sure that you saw this response as an answer to your question, so I am posting it here as an answer. After I wrote it in reply to a comment below, I realize that it actually did a much better job of answering some of your questions more fully, especially the last few paragraphs which illustrate some interventions that are potentially even more impactful.
First, here are some more detailed discussion on the cost-effectiveness from QALYs (quality adjusted life years) which is a metric that values the quality of a year of life multiplied by number of years (section 1) then a brief section on other interventions (section 2).
Section 1
As I noted above, I think there are highly cost-effective interventions that could prevent one circumcision per dollar or more in expectation.
If we assume this reduces sexual pleasure by 20% [1]and that sexual pleasure accounts for 5% of life happiness [2]for average males we could get a rough Fermi estimate of 5% x 20% = 1% reduction in life satisfaction, and if we very, very crudely say that this is similar to losing 1% of 5O years of QALYs, this would be losing .5 QALYs per circumcision, and preventing one circumcision for one dollar would be 2$ per QALY.
I think malaria nets - Givewell’s perennial top charity - are estimated to be about $50 per QALY, so even estimates that were extremely more conservative, like if an intact foreskin only accounts for 5% of sexual pleasure [3]and sexual pleasure only accounts for 2% of overall life satisfaction, it would still be equally effective as bed nets.
More importantly in my opinion, I think most of the harm of circumcision comes from extremely severe PTSD and trauma suffered in rare cases, as evidenced in the Reddit “circumcision grief” and a few studies, and numerous anecdotal accounts I could give. I think some lives are made negative at a ratio of 10:1 to 1,000:1 negative to positive experiences. I would personally say I am in the 10:1 to 100:1 category, despite having healed my PTSD after about three years of it, most men don’t. I suspect it is extremely unlikely my life will ever become positive without life extension/other trans-humanist technology.
I think it is not unreasonable to estimate that 1 in 10,000 men have their lives made net negative at a 10:1 negative to positive ratio (and/or equivalently, made 1:1 negative to positive ratio for 1 in 1,000 men, or 10% worse for 1 in 100 men.) In fact, I think this is conservative based on what I’ve seen; remember this is an experience of genital mutilation as perceived and experienced from the perspective of these men, I don’t think we would question this in the case of female or intersex genital mutilation, and the extraordinarily severe lifelong PTSD that can result. In fact, my understanding is that infant death, loss of the entire penis, and very severe complications leading to permanent extremely limited sexual capability due to circumcision are, combined, far more common than 1/10,000.
That would mean that there is very, very roughly the equivalent of about 50 QALYs (~average American lifespan) lost per 1000 circumcisions, or about 1 QALY per 20 circumcisions. I think the extreme suffering here should count for significantly more, as I think a prioritarian, suffering-biased ethic is probably correct (extreme suffering should be weighed more heavily than average happiness.) And I think the real numbers are possibly much worse than what I stated, perhaps by a factor of 10 or more. But even on this conservative estimate, at one dollar per circumcision prevented, this would be very roughly $20 per QALY, which is again surpisingly good.
Section 2
I think there may be some hits-based leveraged bets that could be 10X to 100X more effective in expectation;
For example, funding scalable trauma treatment (I was working on this and was quite close to finishing a book, and then next was plainning to create a scalable healing program, but burned out and had to quit, partially due to disability and severe funding constraints.) Currently quality circumcision trauma healing is extremely hard to find, so this would be a huge boon, and since I’ve already completed most of the work this can be completed relatively cheaply.
I think $10,000,000 could double the chances of foreskin regeneration happening soon, or perhaps bring it forward by 10 or 20 years in expectation, and I know people who are actively seeking funding to make this happen. Once the procedure is available this can be self-funding - an estimate based on Aella's research gives a $200+ billion market for foreskin regeneration, another indication of value - and as a cultural phenomenon this could lead to much lower circumcision rates or even speed the banning of it in developed countries.
I know some native activists in sub-Saharan Africa[4] who are fundable for a very, very, very small fraction of what US work costs, making this potentially extremely cost-effective, and it is unfortunately highly under-funded. One obstacle here is that we would need some infrastructure set up to make these activists more fundable and effective.
So, all things considered, I think if we are serious about improving the world, we should not dismiss this out-of-hand and at least do a deeper dive into this to confirm how cost-effective it in fact is. All of these are quite rough estimates, hence why I tried to be conservative, deeper research would be needed to confirm.
*Note I did not count flow-through effects here for most of this, and I think flow-through effects could be quite significant.
Most estimates seem to range between 10% and 90%, [5]and it is notable that there is significant methodological difficulty in objectively measuring differences in pleasure, resulting in significant uncertainty here—although there is high information value in investigating further
I don’t think it’s unreasonable to think that a male with no sexual pleasure has lost at least 5% of his overall happiness on average; of course some males value much higher and some much lower
Despite being 1/3 to 1/2 the skin of the penis, being probably most of the nerve endings and almost all of the fine-touch nerve endings of the penis, in addition to providing several significant sexual functions important for both male pleasure and female comfort and vastly increased masturbatory pleasure
My understanding is that circumcision is not at all cost-effective for fighting AIDS compared to other interventions, even if the studies were accurate, but there are some very severe flaws in the studies and more recent research contradicting that there is any positive effect—although strong caveat that I haven’t looked into this deeply.
Do note sexual sensation/pleasure is different than sexual satisfaction, effects on sexual satisfaction seem to be much smaller (although there is also very similar life satisfaction after couple years between new lottery winners and newly acquired paraplegics—cf. narrative life satisfaction vs. direct hedonic wellbeing
Hi Rowan, thanks for your thoughts on this, and for acknowledging that it violates bodily autonomy and reduces sensation. However, I would respectfully disagree that we should out-of-hand dismiss it as an effective cause area.
Why it could be effective
As I noted above in my first comment on Intaction's health equity campaign (HEC) and Intact Global, I think there are highly cost-effective interventions that could prevent one circumcision per dollar or more in expectation.
If we assume this reduces sexual pleasure by 20% [1]and that sexual pleasure accounts for 5% of life happiness [2]for average males we could get a rough Fermi estimate of 5% x 20% = 1% reduction in life satisfaction, and if we very, very crudely say that this is similar to losing 1% of 5O years of QALYs, this would be losing .5 QALYs per circumcision, and preventing one circumcision for one dollar would be 2$ per QALY.
I think malaria nets - Givewell’s perennial top charity - are estimated to be about $50 per QALY, so even estimates that were extremely more conservative, like if an intact foreskin only accounts for 5% of sexual pleasure [3]and sexual pleasure only accounts for 2% of overall life satisfaction, it would still be equally effective as bed nets.
More importantly in my opinion, I think most of the harm of circumcision comes from extremely severe PTSD and trauma suffered in rare cases, as evidenced in the Reddit “circumcision grief” and a few studies, and numerous anecdotal accounts I could give. I think some lives are made negative at a ratio of 10:1 to 1,000:1 negative to positive experiences. I would personally say I am in the 10:1 to 100:1 category, despite having healed my PTSD after about three years of it, most men don’t. I suspect it is extremely unlikely my life will ever become positive without life extension/other trans-humanist technology.
I think it is not unreasonable to estimate that 1 in 10,000 men have their lives made net negative at a 10:1 negative to positive ratio (and/or equivalently, made 1:1 negative to positive ratio for 1 in 1,000 men, or 10% worse for 1 in 100 men.) In fact, I think this is conservative based on what I’ve seen; remember this is an experience of genital mutilation as perceived and experienced from the perspective of these men, I don’t think we would question this in the case of female or intersex genital mutilation, and the extraordinarily severe lifelong PTSD that can result. In fact, my understanding is that infant death, loss of the entire penis, and very severe complications leading to permanent extremely limited sexual capability due to circumcision are, combined, far more common than 1/10,000.
That would mean that there is very, very roughly the equivalent of about 50 QALYs (~average American lifespan) lost per 1000 circumcisions, or about 1 QALY per 20 circumcisions. I think the extreme suffering here should count for significantly more, as I think a prioritarian, suffering-biased ethic is probably correct (extreme suffering should be weighed more heavily than average happiness.) And I think the real numbers are possibly much worse than what I stated, perhaps by a factor of 10 or more. But even on this conservative estimate, at one dollar per circumcision prevented, this would be very roughly $20 per QALY, which is again surpisingly good.
I think there may be some hits-based leveraged bets that could be 10X to 100X more effective in expectation;
For example, funding scalable trauma treatment (I was working on this and was quite close to finishing a book, and then next was plainning to create a scalable healing program, but burned out and had to quit, partially due to disability and severe funding constraints.) Currently quality circumcision trauma healing is extremely hard to find, so this would be a huge boon, and since I’ve already completed most of the work this can be completed relatively cheaply.
I think $10,000,000 could double the chances of foreskin regeneration happening soon, or perhaps bring it forward by 10 or 20 years in expectation, and I know people who are actively seeking funding to make this happen. Once the procedure is available this can be self-funding - an estimate based on Aella's research gives a $200+ billion market for foreskin regeneration, another indication of value - and as a cultural phenomenon this could lead to much lower circumcision rates or even speed the banning of it in developed countries.
I know some native activists in sub-Saharan Africa[4] who are fundable for a very, very, very small fraction of what US work costs, making this potentially extremely cost-effective, and it is unfortunately highly under-funded. One obstacle here is that we would need some infrastructure set up to make these activists more fundable and effective.
So, all things considered, I think if we are serious about improving the world, we should not dismiss this out-of-hand and at least do a deeper dive into this to confirm how cost-effective it in fact is. All of these are quite rough estimates, hence why I tried to be conservative, deeper research would be needed to confirm.
*Note I did not count flow-through effects here for most of this, and I think flow-through effects could be quite significant.
Most estimates seem to range between 10% and 90%, [5]and it is notable that there is significant methodological difficulty in objectively measuring differences in pleasure, resulting in significant uncertainty here—although there is high information value in investigating further
I don’t think it’s unreasonable to think that a male with no sexual pleasure has lost at least 5% of his overall happiness on average; of course some males value much higher and some much lower
Despite being 1/3 to 1/2 the skin of the penis, being probably most of the nerve endings and almost all of the fine-touch nerve endings of the penis, in addition to providing several significant sexual functions important for both male pleasure and female comfort and vastly increased masturbatory pleasure
My understanding is that circumcision is not at all cost-effective for fighting AIDS compared to other interventions, even if the studies were accurate, but there are some very severe flaws in the studies and more recent research contradicting that there is any positive effect—although strong caveat that I haven’t looked into this deeply.
Do note sexual sensation/pleasure is different than sexual satisfaction, effects on sexual satisfaction seem to be much smaller (although there is also very similar life satisfaction after couple years between new lottery winners and newly acquired paraplegics—cf. narrative life satisfaction vs. direct hedonic wellbeing
Check out the health equity campaign (HEC) put on by Intaction. They’ve prevented circumcision from being added to Medicaid in some states, which is known to significantly reduce rates, so for probably something small, I would guess less than $100,000, I would say in expectation they’ve prevented something like 5,000 circumcisions per year as long as these policies stay in place, which could be for several years or even decades, which could mean as low as $1-$2 per unnecessary circumcision prevented.
Much more importantly, Intaction is now lobbying at the capital, and this is the first time this has happened in US history. It will be much harder to have an impact, but the impact could be much higher if it at all adds momentum to broad public debate on the topic and ultimately to the (at least nonreligious) practice being banned completely in the United States, which could have a serious ripple effect throughout the world considering a lot of nonreligious circumcision that exists in other countries has been due to US cultural and pseudo-medical influence[1].
I would also check out Eric Clopper and his lawsuit in Oregon with his organization Intact Global. Establishing the unfathomably severe harm of the practice with a win in the courts seems quite plausible, especially in Oregon where rates are very low, and there’s no question the practice violates equal protection. This could help lead the way to a state ban, which again could be crucial for momentum toward more state bans and eventually a national conversation and potential ban.
Importantly, I think both of these are taking relatively conservative approaches and not trying to challenge religious circumcision directly which is what defeated the attempted ban in San Francisco. It seems important to protect children of all religions from genital mutilation and not discriminate against Jews and Muslims, however, I don’t think this is a realistic/helpful/cost-effective place to start as claims of anti-semitism end up severely distracting from the real issue of severe and permanent nonconsensual genital modifications performed on children.
I think it’s very clear that circumcision has far more medical harms than benefits if you look at the data, and agree that in the US the practice is best conceptualized as genital mutilation intended to prevent sexual pleasure and punish masturbation, which is where its roots in the the Victorian age in the US and UK originated, with attempts only coming much later to justify it medically.