Further Thoughts on Dr. Diekema’s Recent Statements

Now that I’ve rebutted the possibility of a revised AAP position that more favorably supports non-therapeutic infant circumcision, I want to comment on a few additional statements from the interview with Dr. Doug Diekema.

Diekema is aware that there is a movement of “intactivists,” or people who believe that it’s wrong to cut off part of a baby’s body if not medically necessary. “I get huge mailings with FedEx boxes, summaries. I do look at it — I have a file of all of that — but I am not about to let them do the evaluation for me.”

I agree, he shouldn’t substitute anyone’s evaluation for his own. But he should evaluate everything, including the implications of a policy to the individual he acknowledges who might not want that policy applied to his body, permanently. Merely citing the ethical conundrum without drawing a conclusion in favor of the patient, or drawing a conclusion that some possible benefit preferred by someone else for a minor risk justifies setting aside a basic bodily right everyone possesses, is unacceptable.

Diekema said that “hundreds of papers were reviewed and judged for their quality” and that people from the anticircumcision camp “will quote you all kinds of studies — which were frequently terrible and didn’t prove anything because they were so methodologically flawed.”

This is a problem. We should all strive to be logical and accurate. That’s why I don’t cite certain sources and statistics seemingly in favor of my position.

On the other side, it’s also problematic to quote the statistics derived from voluntary, adult circumcision in Africa and apply them to forced circumcision of healthy infants in America. The HIV epidemic is fundamentally different in the two populations. And citing the impressive relative risk reductions without honestly dealing with the unimpressive absolute risk rates and reductions is flawed, as well. This also ignores whether or not the male would prefer an increased risk of HIV transmission from his female partner(s) in high-risk populations. Dr. Diekema acknowledged that not all men would make this trade.

“They don’t like what we’re doing. I get hate mail from them all the time, trying to paint what we’re doing as pro-circumcision. I am conflicted about circumcision personally. It’s a hard choice; it’s a hard decision, and there are good reasons for almost any decision you want to make.” He described his task force as “a moderate group — not pro, not anti. We’re trying to uncover what’s real here.”

It’s not a hard choice. There aren’t good reasons. What’s real here is that the child is healthy. No surgery is indicated. That’s a basic point that should be easily understood and universally applied. That’s the entire discussion. The AAP should declare that non-therapeutic child circumcision should cease immediately.

He said that circumcision removes “maybe 1/3” of the skin on a male’s penis but said that may or may not affect sexual experience. “What you really want to know — ,” he says, “it’s fine and dandy to say circumcision removes all kinds of nerve cells, but more nerves doesn’t necessarily equate to more pleasure — so what you really want to know but can’t look under a microscope and get the answer is: How has the sexual experience changed?”

Ultimately, “we don’t have any good data. Circumcised men may experience sex differently than uncircumcised men — intuitively that makes sense — but it’s simply not the case that we have an epidemic of uncircumcised men that don’t get pleasure or can’t function sexually.” When some men who were circumcised as adults in Africa were asked about the change in sexual function, Diekema says, “most men reported no difference — a small percentage report that it’s worse, and a small percentage report that it’s better. There’s such a psychological component.”

Of course it may or may not affect sexual experience. Human sexuality is complicated, with as many preferences for experiences as there are people. That alone should be enough. The males who would prefer to have their foreskin for its sexual purposes have their preferences superseded by their parents’ preferences. That’s not ethical.

But we already have the answer to a simpler question, whether or not the sexual experience changes. There was a foreskin before circumcision. There isn’t a foreskin after circumcision. That alters the sexual experience. Whether or not that is good or bad is a decision for the male affected, not his parents. The exclusive input on the psychological component is the male who owns the foreskin, not his parents. It doesn’t matter what they think about how circumcision affects – or should affect – his experience. Dr. Diekema said it himself. Not everyone would trade their foreskin. There is only one valid position on this topic.

3 thoughts on “Further Thoughts on Dr. Diekema’s Recent Statements”

  1. I respect your cohcie and your reasons, but I don’t understand why you conclude people circumcise due to misinformation or mindless conformity. I recently had a baby and chose to circumcise him. It wasn’t a given and we felt no pressure to do this. Rather, we studied the issue carefully and discussed with the doctors to see whether there was any compelling medical reason. We concluded that there was. I can see why others would come to a different conclusion, but we found sufficient evidence to support the value of doing this procedure.If evidence showed that the same medical benefits with respect to cancer, STDs, and complications later in life would follow from removing a small piece of a girl’s labia or prepuce, I would have agreed to that too. Female circumcision typically does not stop at this, though, so there is no legitimate comparison between the two. What is the relevant equivalent, for a man, of clitoridectomy? Or of sewing the labia shut except for small holes? What medical benefits has any legitimate scientific study shown from these procedures?The amount of skin removed during the procedure was very small. The baby objected to his legs being immobilized, but had a topical anesthetic and didn’t appear to be in any pain during the actual cutting. He showed no discomfort due to urinating after the procedure, as you suggested above. The comments about the glans becoming desensitized are conjecture do you have any actual evidence of this? Considering that other areas of the penis don’t suffer the same fate, I remain skeptical.I can easily understand why you chose not to circumcise, but it seems like strong feeling about the subject is preventing you from seeing it from another point of view.

  2. Rena,

    I’m sorry, I didn’t see this caught in the spam filter until today.

    I don’t conclude that people circumcise due to misinformation. (Perhaps I said so in another post?) I conclude that they circumcise out of incomplete information. Since you discussed your decision, you do not have complete information. You know what your son needed, which was nothing, since I assume he was healthy. You did not know whether or not he’d want circumcision. It’s his body. His opinion matters.

    The equivalence to female genital cutting is two-fold. In principle, it’s the complete comparison: non-therapeutic genital cutting on a non-consenting individual. It’s ethically wrong.

    In practice, most female genital cutting is more severe than male circumcision. But not always. The anatomical equivalent is removing the clitoral hood. We find that ethically objectionable. It’s also illegal. All female genital cutting, for any reason other than medical necessity, is illegal.

    Why should boys be treated differently? Because male circumcision may reduce some risk of a future malady? That could be true of intervention we could impose. Remove a daughter’s breast buds to prevent breast cancer? The normal human body involves risk. The ability to (possibly) reduce that risk surgically does not render that surgery ethical.

    I respect that your intentions were sincere and you sought what was best for your son. But the act is the problem, not your intentions. Circumcision on healthy children violates the child’s right to decide for himself whether he wants or needs part of his normal penis removed. He may want to keep his foreskin. You can’t know in advance.

    As for the consequences of circumcision, my most important evidence is anecdotal. It’s me. My parents circumcised me. I hate it. I would not have chosen it for myself. I think the scar is ugly. I think the way my penis healed asymmetrically is ugly. And, yes, the way my glans is keratinized is undeniable. I know other men share the same opinion about their bodies because I’ve spoken to them. But the key here is that my parents couldn’t know what I’d want. They may think a circumcised penis is more aesthetically pleasing, for example. I hope it’s clear that I don’t. Why should their opinion rule over my body forever, as it does?

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