Cutting matters more than the “why”

Posted: November 17th, 2014 | Author: | Filed under: Ethics, FCD, FGM, Media Marketing | No Comments »

Mona Eltahawy writes in The New York Times:

I am a 47-year-old Egyptian woman. And I am among the fortunate few of my countrywomen whose genitals have not been cut in the name of “purity” and the control of our sexuality.

This is an important topic. She explains it well as it pertains to Egypt. But this paragraph bothers me:

The practice is sometimes erroneously referred to as circumcision. According to the World Health Organization, it “comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for nonmedical reasons.” The procedure has no health benefits. We hack away at perfectly healthy parts of our girls’ genitals because we’re obsessed with female virginity and because women’s sexuality is a taboo. This cutting is believed to reduce a girl’s sex drive. And families believe their daughters are unmarriageable unless they are cut.

“Sometimes erroneously referred to as circumcision” is meant to distinguish FGM from male genital cutting. “No health benefits” demonstrates this point for the few readers who didn’t catch the “male circumcision is okay” implication¹. That’s nonsense. It’s reasonable to state that the two inflict different degrees of harm in common practice, and that difference can be significant. It is not reasonable to distinguish the two as “acceptable” and “unacceptable”. The World Health Organization quote she used describes male genital cutting, too.

The end of the paragraph demonstrates this point. Were I to write the second half of that paragraph, I’d write it from this perspective:

We hack away at perfectly healthy parts of our girls’ genitals.

That sentence doesn’t need the because. She was correct to include it. It’s relevant for explanation. But the sentence as I wrote it does not need a “because”. It doesn’t matter why we do it, hacking away at a child’s perfectly healthy genitals is always wrong. Get the principle right and the comparison takes care of itself.

For example, does anyone believe Ms. Eltahawy would change her mind if someone discovers health benefits for any form of FGC? Would she be okay with research studies to determine if there are benefits? I wouldn’t. I don’t believe she would. What about cases where her “because” is wrong and parents are honest-but-mistaken in their intent? Nothing changes. The truth that we shouldn’t hack away at a girl’s healthy genitals is clear. There is no excuse for making or endorsing an implication that hacking away at a boy’s healthy genitals is somehow acceptable. People who make the argument Ms. Eltahawy makes in that paragraph advocate for special rights, not human rights.

¹ See also.


Who won here?

Posted: November 4th, 2014 | Author: | Filed under: Ethics, FCD, HIV, Media Marketing, Politics | No Comments »

This video is interesting to me:

The doctor’s evidence-free accusation at the end, “anti-Semitic like you”, is both disgusting and interesting. I side with Brother K’s response and outrage on that charge. The problem is that no one in that video was talking to anyone else. Everyone was talking at each other. I assume all four people walked away thinking they won the interaction. Instead, I want the video where the doctor’s question gets a response rather than an information dump. Show him how his question – and by extension, his view of circumcision – is broken.

His question is excellent: “If there was a vaccine for HIV that reduced the rate by 50%, would you be okay or would you be protesting?” It provides insight into what concerns the doctor professionally. It provides a chance to discuss more about HIV than just this isolated 50% claim. It provides a direct way to distinguish the ethics of vaccination and removing body parts. It provides the doctor an opportunity to experience someone who has thought about this more than just “don’t hurt the babies”.

Non-therapeutic child circumcision is indefensible. The burden of proof should be on those who want to circumcise. They propose intervention. They haven’t proven their case. They can’t prove it because it’s flawed. But society puts the burden of proof on those who challenge tradition, not those who wish to intervene on the healthy body of a non-consenting child. It’s wrong, yes, but we have to work with society tilting at this windmill. Do we want to change society or do we merely want society to know we’re better? My preference is for the former, and especially so when seeing how little the doctor in the video agreed to the latter.

**********

It’s a valid expectation, so my answer to the doctor’s question is this:

Yes, I would be okay with it (qualified by verification of both efficacy and safety of the vaccine within some reasonable bounds). Circumcision isn’t a vaccine. Vaccine’s work with the body’s immune system to trigger a response that then protects the individual from infection. Circumcision removes skin. It operates on the theory of “less skin, fewer entryways”. This is relevant, too, since the mechanism for the claimed risk reduction from circumcision is unclear. Perhaps it’s a confounding factor not yet understood and/or researched? There’s also the scientific fact that condoms work better and do not involve the violation of human rights. And, what about the possibility that removing bits of female genitals could reduce risk? Are we ethically bound to allow that, too, or does it reveal the ethical question we don’t wish to consider? We know it’s unethical to investigate, because the answer doesn’t matter. Our societal fear is convenient, not justified, when it comes to HIV and circumcision.


Deplorable Behavior in Screenshots

Posted: August 10th, 2014 | Author: | Filed under: Ethics, Media Marketing, Mission | No Comments »

8/12/14 Edit: I’ve edited the links in this post because the html was broken. All content remains unchanged.

Disclaimer: Based on what I documented in my last post, I’m unconvinced this disclaimer will be noted or accurately represented by paper0airplane, but I write it with the common usage of the words: The behavior in the linked screenshots is deplorable. It isn’t something I support.

I asked for evidence to support paper0airplane’s accusation that a “prominent intactivist … has decided to set up a database of circumcised boys.” I said it was deplorable and that “[m]y guess is that it’s true,” while asking for a source. That was a simple demand that brought a ridiculous response (that didn’t source direct criticism with a link to my post). That response, addressed here, included this in a comment:

… It’s not a problem to provide their sources. However, I am pretty sure that even if I were to, that fact wouldn’t make it into the blog post.

In what I presume is a passive-aggressive challenge, paper0airplane posted two screenshots to support part of the original claim. I encourage you to review them. They’re repugnant and deplorable. Learn from them what the behavior of an ass can include.

I, of course, expect it to be completely obvious that my original point stands. It is not appropriate to assign the bad behavior of a person to every person who shares a nominal goal. I expect paper0airplane’s behavior in this series of posts to reflect only on paper0airplane, and not well. But anyone else who also incorrectly believes parental choice is legitimate for non-therapeutic child circumcision is not responsible for paper0airplane. I expect the same basic courtesy, which reflects my belief that people are individuals first.

For the record, I do not know the person mentioned in the screenshots, as I wrote twice, nor am I aware of any alias Facebook accounts she might use. I do not use Facebook for my activism.

As for the database mentioned in the screenshots, I have questions.

  • I’m with paper0airplane’s point from the original post. Why? This database doesn’t achieve anything toward ending the practice of non-therapeutic child circumcision.
  • Where is she getting her data? Medical records are private. HIPAA is supposed to protect this data. Is it collected from what people post publicly on Facebook?
  • Is there evidence that this website exists or is under construction? Is there a URL? Is it “merely” pointless, damaging trolling?

The comments in the screenshots aren’t dated, so I don’t know when they occurred. Also, this doesn’t provide evidence that the person was arrested for harassment.


Standards for thee, not for me

Posted: August 9th, 2014 | Author: | Filed under: Ethics, Media Marketing, Politics | 1 Comment »

Partial Synopsis: Deplorable behavior is deplorable, even and especially when it is from people with whom I purportedly agree on a goal. There, so that it’s not missed or misunderstood below.

In my last post about The Case Against Intactivism, I wrote that I think “paper0airplane’s overall approach is that the good intactivists should call themselves something else because the bad intactivists are ruining the term.” I don’t think I believe that any more. Maybe it’s just a week of sloppy blogging from paper0airplane, but this post, Invite Crazy, and its comments do not suggest a willingness to recognize even the most obvious nuance. It’s a smear job.

From the beginning:

The truth about intactivism is that, in the vein of Pro-Life zealots, it is becoming more and more extreme. It’s hard to believe there as many intactivists as there are (though truthfully, there aren’t that many). Honestly, it’s fine with me if you have an ethical objection to circumcision, but medically, there are benefits. It’s up to each parent to decide if those benefits are worth it. It’s up to each parent to decide if it’s culturally or religiously relevant to their family. It’s not up to intactivists. Unfortunately, they’ve decided that it is or should be.

This question begging is not a refutation of the ethical objection to non-therapeutic circumcision of a child. There are potential benefits, both medical and cultural. So what? There are harms and risks, too. The ethical question involves self-ownership, not merely “can we maybe achieve something according to someone else’s subjective preferences” or “but it’s easier if we do it to children”. Bodily integrity applies to the foreskin, just as it applies to every other part of a child’s body, male or female.

In paper0airplane’s paragraph, you see no mention that circumcision has both harms (i.e. costs) and risks. In the comments, paper0airplane writes that doctors are “not harming babies.” That is legally and factually incorrect. Legally, although I am not an attorney, this is basic torts. All surgery is harm. It’s a form of battery. The defense is consent. So it’s not correct to state that doctors are not harming¹ babies. There was a foreskin, then there isn’t. There were nerve endings, then they’re severed. There wasn’t a scar, then there is. There is also surgical risk. This isn’t debatable, although we can. Those are objective harms. The question of harm implicit in paper0airplane’s statement is that of net harm, which is different and subjective. My non-therapeutic circumcision, for example, is a net harm to me because I value all the subjective factors involved differently than my parents valued them, including aesthetics, and I live with my circumcision, not them.

The defense to these harms is, of course, that doctors have consent from parents. The debate centers on the extent to which proxy consent is valid. Intactivists argue that proxy consent should not be sufficient for non-therapeutic genital cutting on male minors, just as it is already not sufficient for non-therapeutic genital cutting on female minors. A male owns his prepuce from birth as much as a female owns her prepuce from birth, and to the same extent that either owns their toes and fingers and legs and arms and so on. There is no magical distinction for the prepuce of a male minor within bodily integrity. There is a valid ethical argument paper0airplane did not refute in that paragraph.

In the comments, paper0airplane reminds that this is a philosophical question. Yep. But the argument that potential (subjective) benefits dismiss ethical concerns is also a philosophical question. For all the criticism of intactivists, some valid, it’s bizarre to approach this with a “Heads I win, Tails you lose” standard, which is still an unconvincing and indefensible rhetorical tactic. Should I assume all proponents of gendered parental rights² approve of this propaganda technique, or is it wiser to direct my criticism at those who engage in it? For me it’s the latter.

A prominent intactivist, who was recently arrested for harassment, and whose revolting commentary on the death of AIDS workers was decried even by other prominent intactivists, including her mentor, Brother K, has decided to set up a database of circumcised boys. This is extremely unnecessary, invasive and honestly just weird. A man can simply look into his pants if he is curious about the status of his foreskin. He knows who his parents are, and can find out who his doctor was. The database is the workings of a mind who is unable to figure out where the boundaries are.

What I read there is that intactivists are attempting to self-police a deplorable tactic. But since that isn’t the lesson I’m supposed to take, let me demonstrate that it is. Just as celebrating the death of AIDS researchers is deplorable, setting up a database of circumcised boys is deplorable. It has no justifiable defense. If I had knowledge of this, I’d criticize it directly. But I don’t, which it’s why it’s critical that paper0airplane provide a source for this claim. My guess is that it’s true, but for someone who criticizes intactivists for playing loose with facts to then accuse without providing evidence for the accusation is embarrassing.

Another prominent intactivist spent 30 years parading with the crotch of his pants painted red, holding signs and taking weird photos of the public that walks by. The easiest question is why. The next question is what does he gain by doing this? An unfortunate answer comes in the way of screen shots of him asking for photos of young boys penises. Not just once, but twice, and probably more. I think it’s obvious the conclusion I’ve drawn.

Again, if true, that’s deplorable. I’d criticize it if I saw it. I haven’t seen it. And again that’s the problem with paper0airplane’s claim. It’s an accusation. The burden of proof for such a scandalous charge rests with paper0airplane.

Leaders like this …

Where is the proof that this is a “leader”? If it is, I’d like to know, too. Self-policing is critical within any activism. Providing evidence lets opponents know, but it also lets nominal supporters know, as well.

… are what is encouraging other intactivists to start creating violent memes, some explicitly threatening the lives of anyone who performs a circumcision. …

Behavior like this is/would be deplorable. Again, source?

… In my opinion, it is only a matter of time until a urologist or pediatrician or OB or mohel is shot or injured somehow. Intactivists, why is this ok with you? …

It isn’t. Be careful with assumptions. And provide evidence so we can denounce those who allegedly do this rather than simply denounce everyone with ad hominem.

… Why do you put up with, support and rally around people who are so off the mark and who totally lack appropriate boundaries, which is vital when you consider the subject. Anyone dealing with a child’s genitals SHOULD be able to tell when they’ve gone too far. Sure, I get it, you consider it a human rights issue, a violation, unnecessary cosmetic surgery. Those are all opinions.

Non-therapeutic circumcision is unnecessary surgery. That is not an opinion here. Its objectivity supports the other words in its sentence more than paper0airplane acknowledges. But again, don’t assume that all intactivists “put up with, support and rally around” this behavior or those who engage in it. I’ve distanced myself from at least one person I’ve interacted with after attempting to convince him of his error. I know others who have done the same with different people. It’s too convenient to assume that the extremists represent the movement, or that moderates support the extremists. Guilt-by-association without evidence to prove accusations, providing no opportunity to address offenders directly, amounts to a smear campaign.

Are those opinions worth someone dying?

Of course not. But how can I personally work to prevent that from happening if I don’t know who to challenge?

The next post is Not violent? You’re mistaken. It has a bunch of pictures implying violence because of circumcision, which are damning and deplorable. Of course, they’re also not sourced to anyone. Some of them appear to be from Facebook, which suggests authenticity. Suggests is not proof. Is it so difficult to anticipate an alternate theory that paper0airplane or someone sharing such beliefs could’ve created these? I do not think that’s what happened. I am not accusing paper0airplane of creating these. I am asking for citations. I believe that’s a reasonable, minimum expectation with both posts.

Recently I noticed a weird bit of misogyny from a Twitter user, @ParentsChoices, who attempted to insult the Blood Stained Men by implying they needed tampons. Are all supporters of parental choice for non-therapeutic male child circumcision misogynists with poor debate skills?

Obviously an unoriginal misogynistic insult is trivial compared to the accusations paper0airplane makes. But I can source a claim that vocal pro-circumcision advocate Vernon Quaintance committed sexual offenses against children. As I wrote in my last post on paper0airplane’s tactic, it wouldn’t be fair or accurate to attempt to smear all advocates for parental choice on circumcision with the misdeeds and crimes of a few. Blame rests only with the specific actors without further evidence. Assuming others support the deplorable actions without evidence of support is unfair.

¹ My concern is the factual claim, not the emotional claim. Self-ownership, not “don’t hurt the babies”.

² paper0airplane claims: “According to the law, parents get those pesky parental rights.” If it’s about the parents and their “rights”, then this pesky “right” would allow them to have their daughters’ genitals cut, too, for the same subjective reasons. “But there are no medical benefits to FGC”, one might say. So? We’ve already been told “[i]t’s up to each parent to decide if it’s culturally or religiously relevant to their family.” It’s too convenient to claim that this parental right is somehow specific to the male prepuce but not the female prepuce for cultural or religious reasons.

Or are we highlighting that “the law” is subject to human error and does not equate directly to human rights, including the bodily integrity of all citizens under its authority?


If the press release says it’s “voluntary”…

Posted: August 1st, 2014 | Author: | Filed under: "Voluntary", Media Marketing, Politics, Public Health | No Comments »

There are few things more predictable in an article titled A Lesson in Health: Scaling Up Voluntary Medical [sic] Male Circumcision than the false use of voluntary. (all emphasis added)

[Seventh-grade teacher at Kopong Primary School in Botswana, Mothusi Joseph] Kgomo and five of his students who were circumcised that day (with their parents’ consent) are a few of the more than 1 million men and youth in sub-Saharan Africa who have chosen to protect themselves and reduce their lifetime risk of contracting HIV by participating in Jhpiego-supported VMMC programs. …

While the unprecedented scale-up of this lifesaving intervention in countries with high HIV-infection rates is impressive, what’s more remarkable are the people who helped make it happen: fathers who brought their sons to clinics, best friends who encouraged their peers, military lieutenants who set an example for their platoons, tribal chiefs and concerned wives, as well as nurses who took on added responsibilities and roles at health centers, and healthcare providers from neighboring countries who traveled long distances to help their fellow Africans during busy VMMC campaigns. …

This article – by Leslie Mancuso, President and CEO of Jhpiego – is adapted directly from a press release (pdf). That press release¹ declares that “More than 1 million men and youth in sub-Saharan Africa have chosen to protect themselves and reduce their risk of contracting HIV by participating in Jhpiego-supported voluntary medical male circumcision (VMMC) programs.” It’s always the same. When public health officials say “Voluntary Medical [sic] Male Circumcision,” they never mean voluntary. Never. I’d suspect the word will eventually be dropped altogether, just as adult disappeared, except it’s useful for the propaganda needed to circumcise healthy children.

¹ How soon before we get another “news” story about Selemani Nyika, Triza Liyasi’s husband, or Lt. Suwilanji Musamba?


The Majority of This Post’s Authors Oppose Unethical Practices

Posted: June 19th, 2014 | Author: | Filed under: "Voluntary", Control, Ethics, Media Marketing | No Comments »

It’s no longer surprising to see the hyperbole concocted to make circumcision appear legitimate. The latest example comes from the Southern Africa HIV and AIDS Regional Exchange, which summarized a survey with the following:

New study in Kenya reveals the majority of women prefer circumcised partners

To summarize the study – Women’s Beliefs about Male Circumcision, HIV Prevention, and Sexual Behaviors in Kisumu, Kenya, by Thomas H. Riess, Maryline M. Achieng, and Robert C. Bailey – the way SHARE does is presposterous. The study involved 30 women, with 23 of them saying they preferred circumcised men. The proper way to summarize it is the second line from the abstract:

Women’s beliefs about MC and sexual behaviour will likely influence the scale-up and uptake of medical MC.

Counter to SHARE’s summary, the authors note (emphasis added):

There are limitations to this study. Since we relied on self-reports it is possible that some respondents could have fabricated answers or not fully disclosed information based on what is socially acceptable, particularly on sensitive topics such as sex and HIV. We did attempt to select respondents who were representative of sexually active women ages 18-35 but given the small sample size and geographic location of our research, our data might not be generalizable to other populations, particularly those where MC is not being promoted as HIV prevention. Our intention has been to gain insights into female perceptions and sexual behaviors related to MC in western Kenya in order to inform and improve programs scaling up MMC for HIV prevention in the region.

It’s misleading to report the study as revealing what the majority of women prefer.

Of course, it’s irrelevant what the majority of women prefer. The ethics center on what the male prefers for himself. In what ways could we rewrite this paragraph to allegedly demonstrate something about what women should do – or have done to them – to conform to the preferences of men?

Respondent: Actually, me personally, I hate uncircumcised men.
Interviewer: Why?
R: I just feel they are dirty and, … this last time, some other guy seduced me, … I didn’t know he was uncircumcised. So when we went out a bit for around four months, so it’s this day was he was telling me like we go to bed, after finding out that the guy is uncircumcised I just told him it can’t work. He should go get circumcised first and come back.
I: So how did he react?
R: Well actually he felt bad, but later he came to understand. That is when he went and got circumcised and we are together now. (25 year-old Luo woman)

Body shaming is body shaming, whoever its target may be. Repeatedly the excerpts emphasize a belief that circumcised men are “clean” and intact men are “dirty”. While the authors note this, and are perhaps genuine, in saying:

… While some women support MC based on their personal experience and beliefs, there may also be the potential for discrimination against uncircumcised men as circumcision programs scale up in sub-Saharan Africa. …

I find no reason to believe public health officials cared or will care. Discrimination is a strategy of these campaigns, as in this awful propaganda ad from Uganda. And the tactic is already paying the expected dividends. The interview excerpts in this study are evidence of that:

I: Do you desire circumcised men?
R: Of course a circumcised one (laughs).
I: Why not the uncircumcised one?
R: I don’t want diseases. (22 year-old Luo woman)

And:

I: And say you get some man who is not circumcised, what will you do?
R: You tell him that circumcision is good, a circumcised person has less chances of getting infected with these diseases, these minor diseases.
I: And if he still refuses?
R: If he refuses you just leave him. (27 year-old Luo woman)

The excerpts also reveal the well-tested “heads, circumcision wins / tails, foreskin loses” approach to sexual satisfaction.

… no matter how the lubrication is, that foreskin will, I don’t know, it moves … and then let me say they don’t stay long. … Yeah they didn’t stay long when you guys are the uncircumcised. Out of curiosity I did ask how come you don’t take long. They say like if that skin is moving it makes them crazy and they release so fast, and I said, okay. And then unlike the circumcised people maybe it’s to our advantage, the ladies, maybe it could be not to them but I think to our advantage they’ll take long. Like they might make you reach a peak faster than the uncircumcised. (23 year-old Luo woman)

The authors state that circumcision campaigns “should ensure that MMC promotion campaigns and counselling are clear that studies have shown that MC does not affect male time to ejaculation.” But campaigns like this count on individuals to sell the message, however well they grasp or fail to grasp that message. Intentionally engaging people to market on behalf of public officials involves spreading anecdotal evidence. There is no comfort or absolution in “the studies show” once they’ve started the game of telephone.

There also remains the possibility that the sources for the claim that circumcision does not affect male time to ejaculation are inaccurate. Note, too, that whether or not the male considers this change good is nowhere to be found. The ethical issue remains absent in this push for networked propaganda.


Human Rights as Politics rather than Principle

Posted: June 17th, 2014 | Author: | Filed under: FGM, Media Marketing, Politics | No Comments »

What is it about the basic concept of human rights that confuses so many people, such as U.N. High Commissioner for Human Rights Navi Pillay:

FGM is a form of gender-based discrimination and violence. It is a violation of the right to physical and mental integrity. It violates the right to be free from torture and other cruel, inhuman and degrading treatment. Because it is almost always practised on young children, it is also a violation of the rights of the child. FGM violates the right to the highest attainable standard of health, including sexual and reproductive health. And when it results in the death of the person who is mutilated, it violates the right to life.

I’d state it as the rights of self-ownership and bodily integrity, but still, even this way it’s easy to understand. Cutting an individual’s healthy genitals without the person’s consent violates rights. So why staple on this (emphasis added):

This harmful and degrading practice is not based on any valid premise. FGM has no health benefits. On the contrary, it generates profoundly damaging, irreversible and life-long physical damage. It also increases the risk of neonatal death for babies born to women who have survived it.

The answer is obvious to anyone who spends any time studying the issue of genital cutting. It’s a method that attempts to distinguish female genital cutting from male genital cutting. It shows up over and over. It’s transparent and wrong because it’s politics at the expense of human beings. The principle isn’t gendered. Non-therapeutic genital cutting on a non-consenting individual violates the individual’s human rights, full-stop. That is the human rights principle involved. The potential health benefits a child’s parents may cite can’t be a valid premise for non-therapeutic surgery without the child’s consent.

That isn’t my primary point here, though. The “FGM has no health benefits” approach is short-sighted and obtuse in the push to end FGM. It contains an implicit argument that FGC – not FGM, because unnecessary genital cutting without consent somehow can’t be mutilation – would be acceptable if some health benefit could be reasonably claimed. It’s a way of saying that human rights are important, but only to the extent that someone can’t find an excuse people are willing to accept as justification for ignoring obvious violations. It demonstrates that the person making the argument does not understand the implications of defending human rights and the courage it requires to be consistent to the principle. This tactic is not a framework for considering humans and their rights. It’s a strategy uninterested in human rights principles. It’s a strategy of manipulating emotions to achieve an ideological goal.

I’m not familiar with the source material, but I think this Friedrich Nietzsche quote I stumbled on today works well in this context (via):

“The most perfidious way of harming a cause consists of defending it deliberately with faulty arguments.”

That’s what the “FGM has no health benefits, so it’s not acceptable like male circumcision” argument is when attached to a human rights argument. If you claim to defend human rights, you have to defend human rights, not the politics of favored human rights.


Some of us wouldn’t dream of having any procedure

Posted: June 5th, 2014 | Author: | Filed under: Ethics, Media Marketing, Pain, Parenting, Science | No Comments »

There is an inherent flaw always present in “parents should decide on genital cutting (but only for boys)” essays. An asinine dismissal of the ethical principle will exist. Although the case against must be made each time, the ethics obviously do not support that stance. Non-therapeutic genital cutting on a non-consenting individual is unethical. It violates bodily autonomy. Any facts supposedly in favor of at least allowing parents to decide can’t overcome this basic principle. So when an essay is titled “Why the decision to circumcise should be left in the hands of the family”, the flaw is guaranteed to be there. It’s the only way to seemingly make the premise hold. Yet, I’ve never seen the flaw so ridiculously written as in Dr. Jeremy Friedman’s essay.

Deep into the essay (emphasis added):

I understand that there are many vocal groups who feel that circumcision has a negative effect on sexual function and pleasure. I also realize that some feel it is unethical to remove something from an infant’s body without a clear medical need and without the infant having some input into the decision.

As a pediatrician, I’m not really professionally qualified to discuss the merits of these viewpoints but I respect the right of those individuals to express them. I am, however, qualified to tell you that babies are capable of experiencing pain and I don’t think it is acceptable to perform a circumcision in a newborn without some form of analgesia. There are a number of different options to prevent pain, and this should be discussed with the practitioner chosen to do the procedure, well ahead of the circumcision.

Dr. Friedman stated that he’s not professionally qualified to discuss the merits of these viewpoints, yet this is the next paragraph, his conclusion:

So what is my take-home message? The decision should be left in the hands of the family. Current medical evidence points to some specific advantages to being circumcised, especially in certain higher risk groups. In Canada I’m not convinced that there is sufficient medical evidence to advocate for circumcision in a family that would not choose it for religious/cultural/family reasons. Nevertheless in those who do choose it, I think they should be allowed the right to proceed, but I will put in a plea for encouraging adequate pain relief. Let’s face it: None of us would dream of having any procedure on this rather sensitive part of our anatomy without it.

He can’t evaluate the validity of individual autonomy for a human being, but he’s qualified to draw a conclusion without concern for the effect on his conclusion from the ethical claim he did not test. That’s pathetic. It isn’t acceptable to punt an aspect of the debate and then claim victory. It’s more ridiculous because he felt competent to draw an ethical conclusion on pain relief. It’s a minor distance from a plea to use pain relief to a plea to refrain from medically-unnecessary circumcision.

**********

In a paragraph aimed at defending parental choice because a study claims the complication rate is lower for newborns, he wrote:

… My interpretation of this data is that when circumcision is performed by adequately trained individuals, complications are infrequent and usually fairly minor. Most common would be infection and bleeding which can be treated quite easily. Nevertheless severe complications such as penile injury can occur, albeit very rarely. If one wants one’s son circumcised then it appears to be much safer if done in the newborn period.

Penile injury occurs in every single circumcision. Less severe penile injury isn’t irrelevant simply because it was intended.


Journalists Doing Brian Morris Undeserved Favors

Posted: April 10th, 2014 | Author: | Filed under: Ethics, Media Marketing, Public Health, Science | No Comments »

It isn’t difficult to see how Brian Morris’ process works. He publishes a “new” paper making bold, biased, often-unsupported claims citing his prior work doing the same, and receives circulation for his ideas from unquestioning journalists acting as stenographers. His latest, with Stefan Bailis and Thomas Wiswell, is a good opportunity to assess the reporting within consideration of an excellent article by Ian Sample, “How to write a science news story based on a research paper“.

1. Find a good paper

That rules out anything written by Professor Morris, but I’ll grant that his focus on non-therapeutic infant male circumcision satisfies the criteria that the work be “controversial”.

2. Read it

You cannot cover a paper properly without reading it. The abstract [ed. note: Or the press release] will give the barest essentials. You need to read the introduction for context, the discussion and conclusions for take-home messages. Check the methods. Was the experiment well designed? Was it large enough to draw conclusions from? Find weaknesses and flaws. You will probably need help to work out how fatal they are. Spend time on the results. Have the authors omitted key data? Look at odds ratios, error bars, fitted curves and statistical significances. Are the results robust? Do they back up the scientists’ conclusions? …

Given that Morris’ latest paper is only 10 pages (pdf), including references, this shouldn’t be hard. Yet, I found no initial article covering it that suggested the reporter bothered to read beyond the press release, or perhaps the abstract. For example, both of these articles cite the “benefits exceed risks by at least 100 to 1″ line as truth, despite there being no support within the paper for this preposterous claim. It’s merely a statement. Where is the support for this in the paper? The questions Mr. Sample suggest provide a path for investigating this paper further. There is a table of potential benefits cited for circumcision, but no data offering how these are weighted to produce an objective mathematical conclusion.

Within the key table listing claimed benefits, Table 4, Morris cites a study by Dr. Jonathan Wright while omitting the necessary qualification that the study found a correlation, not a causal link. As Dr. Wright stated, “‘These data suggest a biologically plausible mechanism through which circumcision may decrease the risk of prostate cancer,'” said study researcher Dr. Jonathan Wright, an assistant professor of urology at the University of Washington School of Medicine. He noted that the study was observational; it did not show a cause-and-effect link.” How much does this correlation contribute to the “100 to 1″ number?

4. Get context

Science builds on science. Know the previous studies that matter so you can paint a fuller picture. …

Like Dr. Wright’s study, for example. Or the way Morris previously used a study by Dr. Kimberly Payne to support a claim that the “highest-quality studies suggest that medical male circumcision has no adverse effect on sexual function, sensitivity, sexual sensation, or satisfaction.” Yet, Dr. Payne’s study, which Morris (and Krieger) rated as the highest quality, resulted in Dr. Payne stating that “[i]t is possible that the uncircumcised penis is more sensitive due to the presence of additional sensory receptors on the prepuce and frenulum, but this cannot be compared with the absence of such structures in the circumcised penis.”

5. Interview the authors

Get them to explain their results and justify their conclusions. What do the results mean in plain English? What do they not mean? Ask your questions in simple language to get answers you can quote. Run phrases you might use past the authors, so they can warn you of howlers. Do not ask multi-part questions: you will not get full answers.

Perhaps Morris should justify making up rights when he says “[d]enial of infant male circumcision is denial of his rights to good health, something that all responsible parents should consider carefully”. Do parents who do not circumcise their healthy son violate his rights?

This is especially interesting in light of a comment in the press release. Professor Morris said (emphasis added):

“The new findings now show that infant circumcision should be regarded as equivalent to childhood vaccination and that as such it would be unethical not to routinely offer parents circumcision for their baby boy. Delay puts the child’s health at risk and will usually mean it will never happen.

If not circumcising an infant male “will usually mean it will never happen”, that demonstrates that circumcision will usually not be necessary. Is this one surgery, and the ethical implication, somehow different than withholding from a healthy child every other surgery that will usually never be required?

This also shows the sleight-of-hand in “half of uncircumcised males will require treatment for a medical condition associated with retention of the foreskin,” which is included in the paper (and on Morris’ site). Requiring treatment is not the same as requiring circumcision.

In footnote e of Table 4, Morris cites a figure for risks associated with neonatal circumcision where “data show that risk of an easily treatable condition is approximately 1 in 200 and of a serious complication is 1 in 5000″. So, a complication is not an argument against non-therapeutic infant male circumcision because it will probably be easily treatable. And treatable medical conditions associated with the foreskin will usually not require circumcision, as Professor Morris states, but somehow also justify non-therapeutic infant male circumcision. That’s “Heads I win/Tails you lose” nonsense. Professor Morris is engaging in propaganda.

When the New York Times quoted Morris about this paper, he said: “Just as there are opponents of vaccination, there are opponents of circumcision. But their arguments are emotional and unscientific, and should be disregarded.” That is demagoguery, and should reflect on Professor Morris’ reputation. The argument against non-therapeutic infant male circumcision is rooted in ethics, but it is also rooted in the science of normal human anatomy. The foreskin is healthy, just as every other body part usually is. And opponents of non-therapeutic child circumcision support condoms, soap, and antibiotics, for example, which are all scientific inventions and discoveries.

6. Get other scientists’ opinions

Such as Professor Kevin Pringle, of New Zealand, and Dr. Russell Saunders, pen name for a New England pediatrician. While I disagree with the latter’s conclusion on parental choice, for my purpose in this post, he wrote: “Having reviewed Dr. Morris’s study, I find his statements about the benefits of circumcision as a routine procedure overblown, and the comparison with vaccination baseless.”

7. Find the top line

How about this, from page 7 of the paper:

The timing of circumcision is crucial. Medical and practical considerations strongly favor the neonatal period (Table 4).16 Surgical risk is, thereby, minimized and the accumulated health benefits are maximized.14,16 …

As Morris’ statement about the likely lack of need demonstrates, circumcising in infancy is not usually crucial for the male’s health to the point of circumcision becoming necessary. There isn’t a justification for non-therapeutic infant circumcision. It can wait until the male can choose – or reject – non-therapeutic circumcision for himself.

8. Remember whom you are writing for

This is where Morris gets what he needs most. The headlines encourage readers who only skim headlines to believe that Morris has proven that the potential benefits exceed the risks 100 to 1, that circumcision is similar to a vaccine, and that there is some case for mandatory circumcision of infants. It’s all absurd and does a significant disservice to readers and truth.

9. Be right

Ahem.


The Equation Is Unnecessary Genital Cutting Minus Consent

Posted: March 23rd, 2014 | Author: | Filed under: "Voluntary", Control, Ethics, FCD, FGM, Logic, Media Marketing, Parenting, Politics | 1 Comment »

Many have heaped scorn on Mary Elizabeth Williams’ Salon piece that criticized Alan Cumming for calling male circumcision genital mutilation and comparing it to female genital mutilation. This scorn is deserved.

Alan Cumming wants to tell you about his penis. He wants it to be a shining example to the world. In a candid interview with Drew Grant this week in the New York Observer, the 49-year-old Scottish actor reveals his strong opinions on “Girls,” naughty cellphone pictures, and, most controversially, circumcision. Or as he puts it, “genital mutilation.”

“There’s a double-standard, which is that we condemn the people who cut off girls’ clitorises, but when it happens to boys,” Cumming says. “I mean, it is the most sensitive part of their bodies, it has loads of nerve endings, and it can go horribly wrong. I’m speaking out against it … I’m just so suspicious of the medical industry, which just flings pills at people to ensure everyone is reliant on things. ‘Here are some pills, Mommy. Take them, and we’ll take your baby away and hack its thing off, and then we’ll bill you for that too.’”

I don’t share Mr. Cumming’s view of the medical industry. Its complicity strikes me as cultural inertia and cowardice. My experience suggests that profit-driven focus on circumcision is limited, although it motivates some. But that’s a distraction. The key is that he is correct about the comparison.

Circumcision of a healthy male minor is mutilation of that male’s genitals. To be valid, it must involve his consent prior to the surgery, not assumed to be later granted retroactively. This is the standard inherent in 18 USCS § 116, which criminalizes all non-therapeutic genital cutting on female minors without regard for parental justifications or potential benefits. The difference we imagine is an accident in the history of Western child genital cutting.

Later in the essay:

… And earlier this week, protesters threatened to disrupt Bill and Melinda Gates’ TED Vancouver talk because of their organization’s efforts to increase the practice in Africa as a means of “limiting the spread of HIV in the parts of Sub-Saharan Africa.”

There is good reason to find the work of the Gates Foundation repugnant, as it pertains to male circumcision. It speaks in the euphemism of voluntary medical male circumcision, when it also means infant circumcision. This is unethical because it violates the principles of bodily integrity and consent. And this study, commissioned and funded by the Gates Foundation, hardly provides reassurance when examining the context of WHO and UNAIDS, who think violating this human right of male children can be legitimized through question begging. Mental gymnastics like that are not admirable.

Cumming’s equation of circumcision with female genital mutilation is an insultingly inaccurate one — boys are not circumcised as a ritualized means of suppressing their future sexual enjoyment,

Although it’s easy to find similar defenses of male circumcision, ritual or not, this implies that the critical issue is intent rather than outcome. Female genital mutilation, in all its forms, is wrong because the female is mutilated, not because she is mutilated for “bad” reasons. Some reasons given are the same as those for male circumcision. And not all females who were mutilated reject or condemn it. Yet all reasons for surgically altering the healthy genitals of a female minor are still bad. This focuses on the principles and facts involved, not our feelings.

Notice, too, how often erroneous claims like “[t]here is no evidence whatsoever to support the notion that it affects function, sensation or satisfaction” are made about male circumcision, as it’s made with that quote from Williams’ link to reader comments on an article. The statement is wrong on its face because circumcision changes the function. If you change the form, you change the function. The function of the penis, including its structure, should not be lazily defined as “to have sex” or something similarly ridiculous. The foreskin is normal anatomy with functions for the penis and belongs to its owner.

The quote is disputable on sensation, considering the (anecdotal) arguments in favor of male circumcision stating that males can “last longer“. Consider the heads I win/tails you lose efforts of Brian Morris here, as all outcomes are assumed to be favorable to overall satisfaction, even when the studies cited do not involve anything near 100% on the subjective evaluation of satisfaction.

nor does a clean male circumcision compare with the often crude, blunt and unsanitary practice of female genital mutilation.

Those qualifiers obfuscate. What about clean female genital cutting compared with crude, blunt, and unsanitary male circumcision? A sterile surgical environment does not grant legitimacy to a rights violation. Again, the act is what matters. There are degrees of harm possible, but the inevitability of harm requires first priority, whatever the degree.

The World Health Organization calls FGM “a violation of the human rights of girls and women” with consequences that include “severe pain, shock, hemorrhage (bleeding), tetanus or sepsis (bacterial infection), urine retention, open sores in the genital region and injury to nearby genital tissue,” while it in contrast notes, “There is compelling evidence that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%.”

WHO also explains that female genital mutilation “comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.” There is no unethical caveat for “but if we find some benefits to female health, or even male health, we’d have to weigh mutilating injury against potential benefits.” That unethical caveat is always applied to male genital mutilation, as Williams does here. An adult male volunteering is not the same as an infant male being volunteered. Consent is the issue, not how horrible female genital mutilation usually is or how innocuous and/or beneficial male circumcision appears to be. Non-therapeutic genital cutting on a healthy individual who does not consent is unethical. It involves harm. Gender is irrelevant to the principle.

One can argue, quite persuasively, about whether the practice of circumcision still has validity here in the West, especially among those who don’t have a religious directive. What’s needed, however, is education and enlightenment, so families can make the healthiest choices for their children. …

I reject the premise. This is a not a decision parents should be allowed to make for their children. The argument that parents may decide this for their healthy children requires this decision to be a parental right. If it’s a parental right, then the prohibition of non-therapeutic genital cutting on daughters is indefensible. The basis for thinking about genital cutting can’t be girls and the parents of boys. That’s absurd.

… It’s not helpful to make far-fetched comparisons, and it certainly isn’t constructive to imply that men and boys who are circumcised are somehow damaged, “mutilated” goods. That’s a shaming technique that serves no one, one that turns having a foreskin into a bragging point. …

Why are we only worried about shaming men and boys by using the term “mutilation”? Isn’t there the possibility or likelihood that women and girls will feel shamed if we describe their genitals as mutilated? Are the psyches of females more able to handle facts?

There is a difference in stating a fact and demanding a value judgment from that fact. The bodies of males who were circumcised as children were mutilated. Their rights were violated. Circumcised males are not obligated to think this is bad or shameful. The obligation (for everyone) rests in understanding that it is unacceptable to perpetuate this violation on their children or to permit its continued practice in society.

Or to put it in terms of individual autonomy, circumcision mutilated me through the deprivation of an essential¹ part of my body. Where I had a normal human foreskin, I now have only scars. My penis is mutilated. No one gets to reject that fact for me. But I do not feel shame. This sense that males might feel shame is what encourages parents to circumcise their sons for conformity. We have to stop being afraid of shame. We’ll achieve that only when we are no longer afraid to state that shame belongs with those who circumcise, not those who are circumcised.

… And it’s an unfair judgment coming from a man who admits, “I myself don’t have kids. I just have managers, assistants, agents and publicists.”

I feel second-hand embarrassment, so that at least someone feels what her statement deserves.

¹ Quibble with essential as something other than an obvious stand-in for normal, and I’ll roll my eyes and ask if normal parts of female genitalia are essential.