Category: Ethics

Coercion Negates Self-Determination

The German court ruling involves many issues, so I expect it to be an ongoing source for posts for the foreseeable future. I’m building my thoughts on the opposition, which is a complex issue. For this post, though, there are a few comments worth mentioning. The full article contains many quotes based on faulty logic, but this comment¹ encapsulates the problem with balancing parental religious freedom with a child’s right to be free from harm:

The Evangelical Church’s Hans Ulrich Anke said: “Religious freedom and parents’ right to choose how to educate their children have not been weighed against the fundamental right of the child to bodily integrity”.

Parents don’t have the right to educate their children with the blade of a scalpel. This is as true about male circumcision as it is for any other surgery, including religiously-argued female genital cutting. The right to be free from obvious, objective harm without one’s consent is not a right that begins upon reaching a society’s arbitrary age of majority. It’s especially fallacious to imagine that this right doesn’t exist from birth for male minors only, as laws against non-therapeutic female genital cutting imply. The fact that male circumcision is proscribed in religious texts demonstrates nothing about the legitimacy of its imposition on a healthy, non-consenting child in a civil society. There are many religious dictates that we do not allow under this expansive view of religious freedom because the actions violate the rights of others. A balancing test is necessary. Where there is a conflict, religion must change, not our protection of the rights of all citizens, equally.

This post by Iain Brassington at the Journal of Medical Ethics blog deftly addresses this conflict for what it is. (Mr. Brassington cites this news story.)

The president of Germany’s Central Council of Jews, Dieter Graumann, called it “an unprecedented and dramatic intervention in the right of religious communities to self-determination”.

That’s telling. The rights of the child give way to the right of a community to cut him. Can communities have rights anyway? I’m not at all sure. If they can, and if self-determination is one of them, does that always have to come out trumps? Again, I’m not at all sure. It’s strange to see rights-talk brought to the table in defence of unconsented, irreversible, and non-therapeutic body modification. If a boy decides that it’s important to get himself circumcised later in life, then that’s a different matter entirely: good for him. But without any choice? I may have missed something, but I don’t understand how the claim is supposed to work. Can anyone help out?

Mr. Brassington succinctly identifies the conflict. The argument is for community “rights” at the expense of individual rights. Effectively, children are property. I suspect critics of protecting a male child’s right to bodily integrity expect opponents to retreat on the basis of some form of fallacy to render reconsideration of existing norms unjustified and offensive. Unfortunately, but with reason for optimism, this is part of the path to achieving full protection of bodily integrity for all individuals.

¹ It’s possible to read that in a different context from the rest of the article. That subtlety may be what he meant, which would rather likely side closer to my view than with the other comments in the article. I will consider it in the context of the rest of the article, as criticism of the court and an attempt to support non-therapeutic child circumcision as a parental religious right.

Outrageous Outrage

In an article discussing outrage at the German court’s ruling, there is this infuriating comment:

Women’s rights groups and social policy makers also condemned the decision, but for the reason that it would have the effect of putting male and female circumcision on the same footing, when they were “in no way comparable”, said Katrin Altpeter, social minister in the state of Baden-Württemberg. Female circumcision she said, was a far more drastic act. It is already outlawed in Germany.

The basic comparison: non-therapeutic genital cutting on a non-consenting individual is a human rights violation. It is unethical, regardless of the recipient’s gender or the extent of the cutting. Katrin Altpeter is wrong.

Ms. Altpeter’s brief statement is the worst form of human rights advocacy. I’m hoping there’s more context to soften it, but if there is, I haven’t found any yet. As her words stand, she divides individuals. She puts forth the offensive notion that because female genital cutting is usually worse, male genital cutting isn’t something that should possess the same legal status. Or, as I’ve said before, it’s the theory that a punch to the face is not battery because a knife to the gut is worse. It’s absurd. Both non-therapeutic female and male child genital cutting can be – are – indefensible to the point of criminality.

Where Ms. Altpeter makes her idea worse is in the last bit of information in that paragraph. FGM is already illegal. The question is decided in Germany, and in the correct way. The court’s decision here doesn’t re-open that. It doesn’t change the reality that FGM is evil and illegal. The ruling moves non-therapeutic circumcision on a child into the same prohibited realm. More than one act is allowed to be bad at one time. Any relevant distinctions can be made in the punishment on a case-by-case basis. It should not be made bluntly with different legal statuses. No child should pay the price so that society can express a little more symbolic disgust.

**********

This doesn’t flow well anywhere in the above, but it’s critical to state. I understand and sympathize with people who object to shifting a discussion from female to male genital cutting when the original topic is female genital cutting. There are conversations where the comparison is relevant and those where it isn’t. The latter probably outnumber the former, and significantly. A legitimate, important clarity is also necessary when comparing the two. The amount of cutting is usually quite different, with possibly extreme disparities in outcome to females versus males. It can work the other way, too, but that’s far less common. The key demonstrable point is that non-therapeutic genital cutting to any extent on a non-consenting individual is unacceptable. That is enough. It should be interjected only when appropriate, an unfortunately subjective standard.

Flawed Circumcision Defense: Yair Rosenberg

In what appears to be an attempt at a GOTCHA! in response to the German court ruling, Yair Rosenberg offers a weak effort touting the potential benefits of non-therapeutic circumcision. He opens:

“Male circumcision is a highly significant, lifetime intervention. It is the gift that keeps on giving. It makes sense to put extraordinary resources into it.”

Who would you guess recently offered this paean to foreskin fleecing? A rabbi? An imam? Nope. Try U.S. AIDS coordinator Eric Goosby at a health convention last month for top officials from 80 countries.

This smacks down the logic of a German regional court that has banned religious circumcision, calling the practice a “serious and irreversible interference in the integrity of the human body.” …

Mr. Goosby’s statement, used as an appeal to authority, does not smack down the logic of the German court. Circumcision can impart potential benefits when it is imposed on a healthy child, while meeting the court’s statement that it is a “serious and irreversible interference in the integrity of the human body”. The imposition on a healthy child makes it unethical. There is no need for an allegedly-required belief that the science isn’t real. Mr. Rosenberg’s argument focuses on ends without a complete consideration of the means.

He next offers the inevitable appeal to a reduced risk of HIV. As almost every advocate does, he omits the relevant caveats. The risk reduction is in female-to-male HIV transmission in high-risk populations. Neither describes the HIV epidemic in any Western nation, including Germany. Even if it did, the studies involved voluntary, adult circumcision, not infant circumcision. That’s the ethical question. Infants can’t consent. They also won’t be having sex any time soon. There is no immediate need to force non-therapeutic circumcision on them for this potential benefit.

His next tactic is revealing. He quotes a story on the HIV studies. The story quoted unnamed federal health officials who declared that the studies were halted early because the findings made it “unethical to continue without offering circumcision to all 8,000 men in the trials”. Okay, fine, they offered circumcision to the control group. Mr. Rosenberg states:

Unethical not to circumcise the men.

No. Researchers deemed it unethical to not offer circumcision to the control group. That’s a huge difference. The control group men retained the right to reject circumcision. One might say this distinction is “highly significant”. Mr. Rosenberg seems to have missed the entire ethical issue. The issue is the imposition of circumcision, not whether or not someone could (or should) conclude that circumcision for himself is awesome because of various possible benefits.

He returns to an appeal to authority:

… The American Academy of Pediatrics is soon expected to come out with a new policy pushing circumcision, reversing its prior stance.

I’m not a fan of the “no medical association recommends it” argument because it’s an appeal to authority and because it could change. But the same problem applies to using a medical association’s support. In the latter case, it’s an evaluation without regard for what the individual needs or wants. It’s untethered from rights and reason.

He continues (emphasis added):

Given this impressive scientific consensus as to the medical dividends of male circumcision, the German court’s judgment—which permits circumcision for “medical reasons”—is a confused and ignorant muddle. Some have rightly criticized it as an assault on millennia of Jewish tradition and practice (not to mention Islam), something one would have thought a German court would be sensitive enough to avoid. But the ruling itself, as the research above amply demonstrates, is logically incoherent and factually wrong for a simple reason: All circumcisions are medically beneficial. Whether or not the procedure stems from religious motivations, it will have measurable health benefits. So by the court’s own reasoning, all religious circumcisions ought to be permissible as long as the parents also want the medical dividends—which effectively means that circumcision has not been banned at all. Of course, it is very unlikely that this is what the court intended and much more likely that it was entirely unaware of the scientific consensus surrounding circumcision’s advantages.

First, it seems clear that the court meant “medical reasons” to mean “medically necessary”. In saying that the court’s reasoning renders non-therapeutic circumcision valid based on merely mouthing the words “medical benefits”, he is echoing the silly argument many push that pretends prophylactic circumcision is “medical” circumcision. It is not. Non-therapeutic child circumcision involves proxy consent, not consent, so the only valid medical reason is need. As Mr. Rosenberg acknowledges, this interpretation is not likely the court’s intent. Assuming that this means the court was unaware of the science is too convenient. It begs the question. “They ruled circumcision is harm, so obviously they didn’t consider the benefits. If they had, they’d know that all circumcisions are medically beneficial and rule accordingly.”

Within either analysis, his conclusion is still wrong. The italicized bit is Mr. Rosenberg’s personal evaluation. It is his subjective conclusion based on his preferences. (He indirectly admits this later.) It is not an objective fact. The only objective fact is that circumcision inflicts some guaranteed level of harm. There is also the possibility of unexpected harm reflected in further complications, which contradicts his “all circumcisions” insistence.

Not everyone will value the potential benefits the way he does. I don’t. The HIV benefit he cites, the one that barely applies to Western societies, is effectively moot if a male simply wears a condom when he has sex. The same ease of prevention applies to HPV, for which there is also a vaccine approved for females and males already exists. And so on. The remaining benefits are generally achievable through less invasive preventions and/or treatments. The most invasive surgical option on children as a prophylactic measure can’t be justified ethically.

Or to put it in extreme terms, is circumcision medically beneficial to the boys who will lose more than their foreskin? What about the boys who die? Is circumcision medically beneficial to them? All circumcisions are medically beneficial, right?

He also misstates the goal of activists:

But that scientific consensus reveals more than just the follies of this German court; it also exposes the deeply problematic aims of American advocacy groups which seek to outlaw circumcision for the entire United States. …

The goal is to prohibit non-therapeutic circumcision on non-consenting individuals. It is not to outlaw circumcision, full stop. That’s his meaning, but precision matters here, just as it does when discussing the reduced risk of female-to-male HIV transmission in high-risk populations.

After trotting out the tired “why do you hate the poor?” argument, he writes:

… It’s one thing to abstain from a potentially medically beneficial procedure due to personal convictions; it’s quite another to enforce those convictions coercively on others.

Children who have circumcision forced on them do not get to abstain due to personal convictions. They had someone else’s convictions enforced coercively on them. If Mr. Rosenberg understands the ethical issues involved, he hasn’t shown it yet.

Ultimately, those who seek to ban circumcision as the essential equivalent of child abuse—from this German court to activists who recently attempted to bar the practice in San Francisco—are doing so in the face of tremendous scientific evidence to the contrary. Their claims are at odds with countless studies, not to mention global health policy. The burden of proof, then, is upon these activists to defend their disregard for this science, not on the majority of Americans who choose to circumcise their children and take advantage of its documented benefits.

This isn’t how the burden of proof works, since proponents of non-therapeutic circumcision on non-consenting children are the people advocating intervention contrary to the normal, healthy body. It warrants an answer, regardless. I do not disregard this science. I accept it all. I just don’t foolishly pretend that the possibility of a benefit permits me to disregard ethics or the vast amount of science beyond claimed benefits from non-therapeutic circumcision. The normal, healthy foreskin is science. The ability of soap and water to cleanse the penis, foreskin included, is science. Condoms are science. The power of antibiotics to treat infections is science. If we are to take Mr. Rosenberg’s narrow reasoning as a valid replacement for ethics, any surgical intervention on a child becomes acceptable if some rationale about possible benefits can be found. There is no limiting principle that respects rights. It’s based on one’s preference for circumcision about one’s child, without regard for what the child needs or might (not) want.

He concludes¹ with this:

After all, individuals are free to discount scientific evidence on the basis of value considerations, even dubious ones, and base their life decisions upon that calculus. But such subjective notions should never form the basis for coercive state policy any more than, well, religion.

Individuals are free to discount scientific evidence on the basis of value considerations. I do. I accept the benefits, but I value other aspects of the issue more. Ethics, bodily integrity, and normal body parts all matter more to me than the possible benefits. Whether that’s dubious or not for me is not for anyone else to decide. Yet I don’t have any freedom on this. My parents had me circumcised. They made my decision on their subjective calculus. It was the basis of their coercive parental policy. If the issue is force, and it is, the only illegitimate force exercised here is circumcising healthy children. Prohibition is the defensible position.

If we want to discuss whether prohibition is the best approach to solving the violation of non-therapeutic circumcision on non-consenting individuals, that’s a discussion worth having. Cultural change is likely to be far more effective. Society, in general, and religions, specifically, have changed. There’s no reason to believe it can’t happen here. It should. It will. In the meantime, though, children are having their decision made with force. Agitating for change through multiple avenues, including the law, is reasonable.

¹ He actually concludes with “Your move, Foreskin Man.” That’s not an argument. I’ve written what I need to say on that topic.

Tempered Hope: German Court Edition

Like every other interested activist, I’m thrilled with the ruling from the District Court of Cologne.

Non-medical circumcision is a “serious and irreversible interference in the integrity of the human body,” the Cologne district court ruled.

This criminalises religious circumcisions performed by Jews and Muslims, the Financial Times Deutschland newspaper said on Tuesday. It says circumcision should be considered a crime of bodily harm.

Basically, yes. And non-therapeutic, non-ritual circumcision on healthy children, I hope. Surgically removing a healthy, normal body part constitutes physical harm. It can’t be much clearer than that. Non-therapeutic circumcision is a “serious and irreversible interference in the integrity of the human body”. There is no parental right to inflict such harm on a healthy child.

The various stories all quote some part of a statement by Professor Holm Putzke. They need to be pieced together to get his full statement, but the good bits I’ve read are here:

“This ruling has enormous significance for doctors,” said Professor Holm Putzke, an expert on law from Passau University in Germany. “For years there has been a call to ban circumcision for religious reasons. The court, as opposed to many politicians, was not afraid of criticism that its ruling was anti-Semitic or harmful to religion.”

Passau [sic – Putzke] further stated that the decision “may not only influence future rulings, but also bring about a change in the worldview of religious people regarding basic rights of children.”

And here:

Meanwhile, Holm Putzke, a professor of criminal law at the University of Passau who has argued for several years for a ban on involuntary circumcision, told JTA he hoped the ruling would spark discussion in Germany about “what should be given more weight – religious freedom or the right of children not to have their genitals mutilated.”

It’s not that complicated. There is no right to mutilate children within the individual right to religious freedom. The right to practice religion is not a right to practice it on another’s body with a permanent, harmful act.

As you can guess, I didn’t need 24 hours to understand that. I didn’t write about this yesterday because I wanted to think on it a bit, and to wait for a little more information to flow out because I can’t translate the source material. The court’s press release (pdf) is only in German, and Google Translate offers a bizarre counter-factual translation. Now that I’ve seen a little more, the key difference between what I know now and what was in the original trickle of information is that this decision is not binding. It’s a precedent in Germany, but it doesn’t immediately outlaw non-therapeutic genital cutting on minors in Germany. It will likely reach higher courts in Germany. This ruling is a victory, but it’s not time to spike the football in the endzone. There’s a long way to go, even in Germany. But it’s a brilliant start worth celebrating. We’ve long known that history will be on our side. This is further evidence.

Where I’d rather focus after the initial high is to suggest we all acknowledge and understand the implications for our efforts, particularly in the U.S. When the San Francisco ballot initiative began last year, that was a win. It became a minor setback for other reasons, but the initiative was correct. The text of the proposed legislation clearly identified the right and why it was generally applicable rather than an attack solely on religion as some inexcusably declared.

Still, the initiative had a flaw. The opportunity was specific to California and its ballot initiative option. It was worth pursuing (if there hadn’t been a controlling law on city versus state regulations already in place). It just shouldn’t have been in San Francisco. That was a tactical error. The city has a reputation outside of its boundaries that added unnecessary baggage to the effort. It allowed people uninterested in simple critical thought to suggest and accept that the initiative was on par with banning Happy Meals. The initiative involved liberty interests (i.e. individual bodily autonomy and genital integrity) that would’ve been helped by not being associated with unrelated silly endeavors.

So it is with this ruling. There’s more than just “we’re right!”. The case involved a Muslim family, which is being lost in many of the news reports and blogs reporting it. But the connection with and implications to Jewish ritual circumcision are obvious. If the ruling sticks and applies throughout Germany, it will affect both religions. That is legitimate. Again, circumcision inflicts physical harm, as the court found. Non-therapeutic reasons can’t excuse its imposition on children. That’s the rational extension of the finding. The elephant in the courtroom is the prohibition in Germany of an act associated with Judaism.

Ridiculous people will focus on this with hysterical hyperbole, but there are also reasonable people discussing it. It can’t and shouldn’t be dismissed. We should not feel ashamed or apologize for this unfortunate connection. It’s noteworthy but far too simplistic as an attack point. We should be cognizant of history and be responsible in how we talk about the ruling and its inevitable opponents within (and beyond) religious communities. History matters, but it can’t be an excuse to avoid the present. It can’t be a defense for uncritical thinking, for the wrong idea that non-therapeutic circumcision on a minor is an extension of a parent’s religious freedom. Religious freedom for parents and bodily integrity for children are consistent within the same civil law. We have the principles on our side. Let’s be intelligent about how we focus the discussion – and refocus it, if necessary – on rights and the future rather than solely on the past.

Self-Ownership and Parenting Coexist

Katia Hetter wrote a fantastic essay at CNN, titled “I don’t own my child’s body”. It’s in response to the Sandusky molestations, and is worth reading on its own for that reason.

It’s also impressive because it captures the spirit of genital integrity as part of the more general realm of children having rights separate from their parents. Children are individuals, too. I most respect that she explains that her child is an individual while still demonstrating that she parents her child. Recognizing and respecting a child’s individuality and self-ownership is a part of parenting, not a suggestion that, as a result, parents may not make any decisions for the child. Some ardent circumcision advocates, masquerading as advocates for “parental choice” (for sons only, somehow), trot out the latter, absurd trope whenever someone suggests that children own their healthy, normal bodies. This essay serves as an effective disinfectant for that nonsense.

My daughter occasionally goes on a hugging and kissing strike.

She’s 4. Her parents could get a hug or a kiss, but many people who know her cannot, at least right now. And I won’t make her.

“I would like you to hug Grandma, but I won’t make you do it,” I told her recently.

“I don’t have to?” she asked, cuddling up to me at bedtime, confirming the facts to be sure.

No, she doesn’t have to. And just to be clear, there is no passive-aggressive, conditional, manipulative nonsense behind my statement. I mean what I say. She doesn’t have to hug or kiss anyone just because I say so, not even me. I will not override my own child’s currently strong instincts to back off from touching someone who she chooses not to touch.

I figure her body is actually hers, not mine.

Exactly.

Link via Attorneys for the Rights of the Child (link), on Twitter.

A Function of the Foreskin

There is an ongoing thread on this post, “When bad science kills, or how to spread AIDS”, by Brian Earp at the University of Oxford’s Practical Ethics. The post is worth considering, but within the nearly 600 comments (so far), a great debate developed that illuminated many points on the science and ethics of non-therapeutic circumcision, as well as some necessary lessons in etiquette. I’d like to excerpt a comment I left today. Within a larger comment, I addressed the belief that the foreskin’s function was an evolutionary response we no longer need, a position pushed¹ by Brian Morris and Edgar Schoen. Here it is:

5) Circumcised penises are not fully functional. The foreskin is a normal part of the penis. Removing it eliminates at least one aspect of a fully functional penis (i.e. gliding motion). Even if we accept the strange thesis argued here by Jake (and shared by circumcision advocates Brian Morris and Edgar Schoen) that the foreskin’s role was solely to protect the penis from “twigs and long grasses before humans wore clothing”, modern clothing still poses a danger to the penis. Better to have the foreskin caught in a zipper than a “useful” part of the penis caught, right?

If protection was a function, protection is a function. That doesn’t disappear because we’ve developed clothes. Shall we also deny the existence of nudists?

Whether or not that loss of function is good or bad is subjective to the individual to decide for himself. That is the issue of self-ownership. The simple truth of “it’s mine” is enough reason for someone to keep a normal, healthy part of his/her body that he/she hasn’t agreed to give up. That is the ethical issue involved.

The “twigs and long grasses was its function” idea has always struck me as stupid, transparent propaganda.

¹ For Morris’ version of this, search his site.

Flawed Circumcision Defense: Dr. Ruth Westheimer

At the risk of being impolite to Dr. Ruth Westheimer on her birthday, here’s a reminder of how lacking her position on male child circumcision is. From an advice column from 1995:

Dear Dr. Ruth: There is a good deal of anti-circumcision opinion in circulation these days and I would like to get your opinion. One of the claims is that circumcision results in a reduction of sexual pleasure. The argument, which sounds logical, is that exposing the glans reduces its sensitivity and that therefore the uncircumcised penis affords more sexual pleasure than the circumcised one. Sounds plausible, but is it true?

I think that many of today’s young parents, Jewish and others, who like to do what is “politically correct” might well forgo circumcision of their sons if that condition would mean someday depriving them of a measure of sexual pleasure.

Can you suggest any kind of evidence which either supports or challenges this claim?

Dear Reader: While it is true that one of the long-term effects of circumcision is some loss of sensitivity in the glans, or head of the penis, what you must realize is that sex really takes place in the brain, and so long as the man is in a loving relationship, there will be many compensating sensations taking place in his brain to replace those he might have lost in his penis.

She answers the question correctly (with an answer contrary to the mistaken opinion many hold today, almost 17 years later). While I understand what she’s doing, using the bulk of her answer to disregard the implication of her initial statement is inexcusable. The question involved children, not how to comfort a circumcised adult sexual partner. This disregard is still all too familiar today. “It affects his sexual pleasure, but…” There is no valid defense of that “but” for non-therapeutic circumcision on a child.

On her website, she answered another circumcision question. It’s undated. I assume it’s (considerably) more recent than 1995. It doesn’t matter. (emphasis added)

[Reader:] My wife and I are expecting, and we are not finding out the sex. However, if we have a boy, she is adamant that we not circumcise him, and I am adamant that we do. I have researched article after article about the hard medical facts of circumcision and how it lowers the transmission rates of STD’s such as HIV. It also helps with penile carcinoma, UTI’s, and ulcerative STD’s.

My intelligent wife believes that we should offer our son a choice of whether he wants it or not, and is afraid our son will feel the pain if he has it.

I am circumcised, and want my son to ‘look’ like daddy, as well as not have to explain to him at a younger age as to why he is so much different than daddy.

I’m interrupting here to highlight what is obvious. The father talks about all of the benefits he has researched. Yet, his statement makes it clear that his real reasons are that he wants his son to look like him and to avoid the need to parent his child with an explanation for why his son is “different” (i.e. normal). This is even though a son won’t ‘look’ like daddy for at least a decade after circumcision, which he will still have to explain if it comes up. Better to act like a parent and explain his normal, healthy body to him than to pretend that his dad’s insecurities justify surgery. (These insecurities will appear again.)

Furthermore, if the procedure is done later, our son will be in pain for six weeks, and I just don’t want him to have to endure that torture. [ed. note: so it’s acceptable to force him to endure that as an infant?]

As circumcision requires both parents consent, this matter will not resolve itself. I feel that my wife should consent as I have more experience in this matter than she does. [ed. note: This is stupid. Would he abdicate his responsibility as a parent if his wife wanted their daughter cut?] I would also feel inferior when our son asks, ” Daddy, why did you cave in to mom’s demands?” later in life. [ed. note: Protecting your children from harm is the “manliest” thing a father can do. Don’t pretend this is about proving your power and ego.]

We are at an impass. We are both passionate about our beliefs (she would consent to having our son circumcised if I were Jewish). What can I do? Should I let this battle go?

Before getting to Dr. Ruth’s answer, I didn’t interject into this man’s question to mock him. I only seek to indicate how obvious the rebuttals are that a good advice columnist would offer about this parenting question. His approach is quite common, so it shouldn’t be unfamiliar to Dr. Ruth. She didn’t go that route, of course.

[Dr. Ruth:] While it’s OK to have differences of opinions, I would hope that you don’t have to have actual battles over these issues. Perhaps because you’re both acting so stubborn, neither one of you is willing to listen to reason. And at this point, you don’t even know if it’s going to be a boy or a girl!

While you raise good points regarding the health concerns, those risks are greatly reduced if it is a boy and you teach him to clean his penis thoroughly. [ed. note: Indeed.] I know not every young male does a good job at that, but if this is important to you, then you’d just have to make it your duty to make sure he does. [ed. note: Parenting… What a useful answer.]

Your wife’s point that the decision should be his does not sound very intelligent. It is much worse to have this procedure when you are older, so the decision must be yours when he is quite young. If that’s her only concern, then perhaps your argument that you want his penis to look like his dad’s has more weight. But in the end, this is not such an important issue and rather than fight over it, you should have some reasonable discussions, if the baby turns out to be a boy, and see what happens. But better to lose this particular debate than fight with your wife.

Dr. Ruth’s last paragraph is a complete mess devoid of ethics. The wife’s point is the only intelligent opinion uttered throughout. As Dr. Ruth answered in another question (about an adult), “[i]t’s his penis …”. Yes. In that other question, if the argument that it’s his penis weren’t the correct answer, Dr. Ruth should’ve told the woman asking that question to demand that her boyfriend get circumcised. She didn’t. Self-ownership exists from birth. It is not negated simply because a boy’s parents fear a possible future outcome.

That gets to Dr. Ruth’s next failing here. She omits the critical point. What is the risk he will need to be circumcised later? It’s quite low, of course. In addition to the more important fact that there is no decision to be made now, there will likely never be a decision that needs to be made. Whether or not he might deem the prospects of adult circumcision to be worse is irrelevant. It does not mean the decision must be his parents’. Dr. Ruth’s opinion is not intelligent. Justifying cosmetic surgery on a son to appease his father’s ego is not intelligent, either.

(Her last sentence is an accidental correct answer. She found her way to a good suggestion premised on an awful reason.)

Circumcision: A Limited View of Science

I posted the following on Twitter today:

It’s bizarre how insistent many circumcision advocates are that science only exists on the blade of a scalpel. Science is so much more.

I think this is a decent summation of the accusation many circumcision advocates make to discredit the fight for equal genital integrity and bodily autonomy. They claim, whether or not they believe it, that disapproving of non-therapeutic circumcision on children somehow signals a rejection of science. That’s nonsense, bordering on ad hominem. It’s the same thread of empty rhetoric that created a brief spurt of “so you want Africans to die of HIV?” when researchers released the first HIV trial results.

The problem is obvious. Rejecting the non-therapeutic circumcision of children is not a rejection of science. In critical ways, it’s an embrace of science and its power lacking within circumcision advocacy. It’s a recognition that science is so much more than what happens from the blade of a scalpel. It’s an acknowledgement that we are not so primitive that we must fear risks that circumcision aims to reduce. The diseases are not shrouded in mystery warranting immediate, radical intervention on healthy children.

By definition non-therapeutic (i.e. prophylactic) child circumcision occurs on a healthy child. His health is scientific. This must not be omitted from the discussion. No genital surgery is indicated, just like no heart surgery, brain surgery, or any other surgery is indicated or justified. We don’t call those who reject other interventions that may achieve some potential benefit anti-science because good health as science is an obvious concept. It wraps with ethics, and we have no agenda elsewhere. The same can once again be true of the foreskin within society as a whole.

It’s also useful to remind those who accuse opponents of non-therapeutic child circumcision of being anti-science that science developed preventions and treatments for the diseases and infections that prophylactic circumcision targets. Antibiotics are science. The HPV vaccine is science. Condoms are science. The list of options available before resorting to circumcision is vast. We advocate for science and the ability scientific progress grants us to apply conservative, non-invasive interventions to prevent or resolve medical problems. The charge that we are anti-science because we do not advocate for the most extreme intervention possible is ludicrous.

Two simple questions are the most powerful rebuttal we have. Why is the science supposedly encouraging circumcision – the subset of science convenient to that position – the only science on which we’re supposed to focus? Why should we ignore most of the tools the human mind has uncovered that allow all of us, including intact males, the opportunity to live healthy lives? Considering the full realm of science promotes the proper ethical application of science that protects the rights of individuals as human beings with full bodily autonomy. Advocating for non-therapeutic circumcision on non-consenting individuals is the weaker scientific position.

More on the Fallacy of VMMC: Infant Volunteers

Following on last week’s post detailing how voluntary is deceptively dropped from “voluntary male medical circumcision” (VMMC) when convenient, it’s worth demonstrating how the U.S. government engages in the same unethical behavior. Both USAID and PEPFAR are guilty.

Starting with USAID, its Technical Brief (pdf) on Medical Male Circumcision and HIV Prevention drops voluntary from the title of the document. Then, despite including the “V” in the document, it writes (italicized emphasis added):

Providing VMMC Services

As targeted activities progress, demand for VMMC services by interested adolescent and adult males and the parents of male early infants has increased. …

Costing and Impact Summary

To further support VMMC program planning, PEPFAR worked through USAID to collaborate with Joint United Nations Programme on HIV/AIDS (UNAIDS) to develop the Male Circumcision: Decision Makers’ Program Planning Tool to assist countries in developing policies for scaling up services to provide VMMC. This tool allows analysts and decision makers to understand the costs and impacts of different policy options regarding the introduction or expansion of VMMC services. It is part of a larger toolkit developed by UNAIDS/WHO that provides guidelines on comprehensive approaches to VMMC, including types of surgical procedures and key policy and cultural issues.

The key policy topics addressed by the model are:

  • Identifying all male adults, adolescents, and early infants; targeting coverage levels and rates of scale-up
  • …

Key conclusions from an initial desk review study presented at the International AIDS Conference in Vienna,Austria, in July 2010 indicate that scaling up VMMC programs to reach 80 percent coverage of adult and early infant males within 5 years could potentially:

  • …

The entire report is preposterous for how uninterested USAID is in dealing with the obvious ethical problem. Society has simply accepted that, as long as someone “volunteers” a person, that person has volunteered for circumcision. There’s no apparent sense that ethics matter, or that language indicts interest and intentions.

Notice, too, PEPFAR’s cooperation with USAID to ignore voluntary. It continues within PEPFAR documents. First, from “Smart Investments: Making the Most of Every Dollar Invested” from February 2011 (italicized emphasis added):

Medical Male Circumcision

Medical male circumcision (MC) is an ideal HIV prevention investment for countries and donors as it is a time limited intervention. The majority of the expenditure required to saturate a country with high levels of adult male circumcision takes place in the first 1-3 years, depending on the speed of the program, and expenditures drop precipitously following this initial investment to support neonatal and adolescent boys. Scaling up of MC to reach 80% of adult and newborn males in 14 African countries by 2015:

  • …

As expected, voluntary makes no appearance. Instead, the passage just assumes that adult and infant circumcision are the same. No differences, no questions raised in the latter. It’s pure utilitarian decision-making without concern for the patient. The individual is merely a part to be directed.

Next, more blatantly, PEPFAR’s “Guidance for the Prevention of Sexually Transmitted HIV Infections” (pdf) contains the following (italicized emphasis added):

4.2.2 Voluntary medical male circumcision (VMMC)

Evidence

Voluntary medical male circumcision is the surgical removal of the foreskin from the penis [ed.note: of a consenting adult] by trained medical personnel under aseptic conditions. …
…

Program Implementation

Countries with a low prevalence of male circumcision and high HIV prevalence should initiate and accelerate steps to increase the availability of VMMC services. As with other prevention methods, considerations of access and cost, as well as cultural, ethical, and religious factors can hinder the widespread implementation of VMMC. …

Implementation of the comprehensive HIV package: Where VMMC services are provided, … PEPFAR will support programs, in keeping with national strategies, that: implement the comprehensive package; adopt culturally-appropriate strategies; utilize well-trained practitioners working in sanitary conditions; maintain informed consent and confidentiality; and avoid any form of coercion.

Targeted implementation: UNAIDS and WHO advise that the greatest public health benefit results from prioritizing circumcision for young males (such as those aged 12-30 years), as well as men thought to be at higher risk for HIV (such as those in discordant couples or being treated for STIs). Circumcision of newborn babies should be promoted as a longer-term strategy. VMMC for men living with HIV is not recommended but should not be denied if requested.

Short-term, accelerated implementation: … Once intensive service provision accomplishes “catch-up” circumcision for adolescent and adult males, sustainable services need to reach only successive cohorts of young adolescents and/or newborns. These”catch up” programs require awareness and behavior change communication campaigns wherein political and social leaders promote VMMC. …

PEPFAR didn’t bother to drop the “V” from voluntary medical male circumcision. It just pretends that any circumcision of a male is voluntary. According to PEPFAR (i.e. the U.S. government), a 12-year-old male is the same as an adult and can volunteer with full, informed consent. I believe that’s possible, but not in any way applicable to all 12-year-old males. (This is especially true given how rarely advocates provide any mention of the functions and benefits of the foreskin.) It’s in no way applicable to any infants, yet that is the long-term strategy PEPFAR is pushing. Voluntary has disappeared as a consideration.

Even accepting the flawed view of the success possible from pushing circumcision of infants for HIV prevention, what happens if it proves successful? Those locations become populations with high prevalence of circumcision and low prevalence of HIV. They become the exact opposite of what they say in the above and in this from the Evidence section:

WHO and UNAIDS have concluded that VMMC should be actively promoted as part of comprehensive HIV prevention efforts in settings where circumcision rates are low and HIV prevalence is high. …

Its own success would render it no longer ethical (within the unethical frame of “voluntary” infant circumcision). Would advocates stop pushing circumcision – infant circumcision, specifically – as an HIV risk reduction method? Given the behavior of U.S. advocates, including the AAP, I’m skeptical.

I’m not doubting their sincerity. I believe people can be sincere in their ideas as a result of flawed, poorly examined assumptions. I doubt their sincerity in accepting the correct assumption that voluntary medical non-therapeutic male circumcision may be advisable only in areas with low circumcision rates and high HIV infection rates. Infants do not volunteer, and there’s a long grace period during which better (or complete) prevention methods may be discovered. Or advocates might remember that condoms are necessary, regardless of circumcision status. But they don’t. Somewhere the goal not-so-subtly morphed from “circumcision for HIV prevention” to “circumcision and HIV prevention”. As the last century-plus demonstrates, advocates of circumcision tend to believe that circumcision justifies itself. What an individual might want in the absence of need (i.e. ethical, voluntary circumcision) fades to public policy insignificance, or worse, becomes assumed away to a position where infants beg to be circumcised now. Reports on VMMC that are really just a push for MC provide modern, ongoing proof.

**********

This additional bit from PEPFAR’s guidance is informative, as well:

Current evidence strongly supports VMMC‘s effectiveness in preventing infection of men in penile-vaginal intercourse, but not in penile-anal intercourse. While statistics have been inconclusive thus far on the efficacy of circumcising MSM to prevent infection, the procedure may be worthwhile for individual MSM, especially those who also engage in sex with women. …

Statistics have been inconclusive, but it may be worthwhile. That’s “heads I win, tails you lose” analysis in pursuit of circumcision for the sake of circumcision.

Politics: Legitimate and Illegitimate Medicine

I strive to avoid political topics here that stray beyond direct, immediate applicability to genital cutting. We all have our own set of beliefs. I have mine, but I do not wish to turn anyone away from Choose Intact’s focus because we disagree on something unrelated. I write this with that idea in mind, although I don’t think the comparison I’m about to make is particularly controversial.

The challenge we face as advocates for bodily integrity and autonomy for all revolve around the two core facts in what we oppose: non-therapeutic genital cutting on non-consenting individuals. This story (from 11 days ago) involves a comparison on both points (emphasis added):

A District Administrative law judge Monday refused a request from a Wisconsin Avenue pain doctor to reverse temporarily a decision by the DC Department of Health that stops him from writing prescriptions for powerful pain medications.

Dr. Alen Salerian runs the Salerian Center for Neuroscience & Pain in far Northwest, and had his right to prescribe Class Two narcotics suspended earlier this month. That action followed by less than two days, and contradicts, a Drug Enforcement Administration decision that allows him to write these prescriptions until 2015.

In court documents, The Department of Health maintains Salerian “has prescribed highly addictive controlled substances to patients without medical sufficient necessity.”

With pain management, the government prohibits a doctor-patient relationship where a therapeutic need exists and all parties consent in order to achieve some tangential (i.e. irrelevant) political objective. That is, our government holds the belief that “Drugs are bad” higher than the care and well-being of individual citizens. It rejects science because it’s not politically acceptable. Real people are suffering because we’re allowing politics to prohibit medicine.

With genital cutting, the government creates a doctor-patient relationship where no therapeutic need exists and not all parties consent in order to order to achieve some tangential (i.e. irrelevant) political objective. That is, our government holds the belief that “Parents may choose (for their sons only)” higher than the care and well-being of individual citizens. It rejects science because it’s not politically acceptable. Real people are suffering because we’re allowing politics to encourage culture masquerading as medicine.

As I said, I have an opinion on the story beyond the scope of this blog. If yours differs, I think and hope we can disagree without disputing the hypocrisy this post highlights. Here we have a scenario for activists that demonstrates exactly why the individual needs to be the primary concern in our activism for genital integrity. Anything that disrupts the focus from individual people – the distinction between patient and victim – is our target. We need to continue interacting with our elected representatives to eliminate this hypocrisy and to correct our approach to rights, ethics, and science. It’s currently skewed away from all three. If our representatives won’t listen, we can and should work to elect new, better representatives.

Link via The Agitator.