Flawed Circumcision Defense: Children’s Urology, Austin

Posted: February 3rd, 2015 | Author: | Filed under: Ethics, FCD, Media Marketing, Parenting, Surgery | No Comments »

Hey, a press release (Links omitted):

New Austin parents wishing to heed the American Academy of Pediatrics and the Centers for Disease Control recent guidance on circumcision, which endorse the procedure because of resulting health benefits, have access to a new in-office resource dedicated to circumcision — the Newborn Circumcision Clinic at Children’s Urology.

The CDC’s draft proposal aimed at medical providers has not been formalized as a recommendation. It says so in the public notice (emphasis added):

“… The draft recommendations include information about the health benefits and risks of elective male circumcision performed by health care providers.”

Even though the press release acknowledges the draft status of the proposed recommendations, Children’s Urology uses the draft proposal to sell non-therapeutic circumcision. That’s odd.

It’s odder still because the CDC’s draft proposal ignores the direct physical costs of circumcision to the patient. The CDC’s draft proposal stumbles on the ethical analysis of applying the potential benefits to healthy children. The CDC’s draft proposal fails to mention or evaluate many options for prevention and treatment of maladies that are less invasive and more effective than circumcision, such as the HPV vaccine. The CDC’s draft proposal is half-baked. Half-baked is a poor basis for eliciting any level of informed consent.

There’s a reason this next paragraph closes the Notice document:

In addition to obtaining public comment on the draft Recommendations, CDC considers this document to be important information as defined by the Office of Management and Budget’s (OMB) 2004 Information Quality Bulletin for Peer Review and, therefore, subject to peer review. CDC will share the summary of public comments with external experts who conduct a peer review of the evidence on this topic. Their review will include an evaluation of completeness, accuracy, interpretation, and generalizability of the evidence to the United States and whether the evidence is sufficient to support the draft counseling recommendations.

No worries, though. The Newborn Circumcision Clinic at Children’s Urology is ready to sell new Austin parents surgery for their healthy sons. It says so in their press release. Jillian Moser, PA-C, or someone on the circumcision provider team, will circumcise the healthy baby if he’s six weeks old or younger, weighs 10 pounds or less, and has normal appearing anatomy. The circumcision provider team does not require a boy to need any form of intervention before they’ll perform surgery. One might be inclined to think that a strange requirement to dismiss. However, lest healthy newborn boys worry they might not be in good hands, Children’s Urology knows what healthy newborn boys care about most for their genitalia: the comfort of their parents.

“Our Newborn Circumcision Clinic offers a comfortable, in-office experience for families interested in following the recommendations and pursuing circumcision for their son,” said Leslie McQuiston, MD, pediatric urologist at Children’s Urology.

Of course, it’s curious that Leslie McQuiston, MD, believes the CDC’s draft proposal a) targeted parents and b) recommends circumcision of newborns. Either of those beliefs suggests that Dr. McQuiston hasn’t read the CDC’s draft proposal (or the longer document that supports the draft proposal). The claimed link to the CDC’s draft proposal in her clinic’s press release loads a PDF announcing the draft proposal for public comment. Since Children’s Urology doesn’t seem to know where the actual draft proposal is located, it’s possible they haven’t read the draft proposal, which would be understandable. Who has time for reading dense material when so much science needs urgent applying to healthy children? Healthy children can’t possibly wait for the draft proposal to be finalized, much less wait until they might have a need for the most radical intervention. The science of newborn male genital anatomy isn’t scientific without a scalpel, after all. Duh. Everybody knows that.

Maybe the confidence of new Austin parents wouldn’t be so high after considering the totality of evidence from Children’s Urology’s press release. Trust them, though. Right in the press release, it says their clinic is “the premier pediatric urology practice in Central Texas,” and that it “specializes in the medical and surgical treatment of genitourinary conditions from birth through adolescence.” That’s great, and probably true, but we’re all now thinking the same thing. Okay, maybe the folks at Children’s Urology aren’t thinking this, but most of us not selling surgery on healthy children to parents using a flawed draft proposal are thinking it. Circumcision isn’t a genitourinary condition. I know, right? It seems obvious. But, on the contrary, we’re all wrong. It says so right on Children’s Urology’s site, under Conditions We Treat.

Genitalia

  • Ambiguous Genitalia¹ (DSD)
  • Chordee
  • Circumcision
  • Concealed / Hidden Penis
  • Epispadias
  • Hypospadias
  • Labial Adhesions
  • Meatal Stenosis²
  • Micropenis
  • Phimosis

I know, I know. It’s weird that circumcision is offered to treat the genital condition, “circumcision”. It’s weirder, I guess, because Children’s Urology convinced me we agree. Parents, doctors, activists, the AAP, the CDC, and Children’s Urology all need to work together to eradicate this awful scourge, circumcision, that somehow persists for healthy boys in modern society.

¹ I’ll refrain from speculating on this item because I do not know what Children’s Urology recommends for these children.

² It’s worth remembering that meatal stenosis and adhesions are possible complication from circumcision (i.e. the treatment for the condition, “circumcision”).


Framing with Reason or Emotion

Posted: December 11th, 2014 | Author: | Filed under: Media Marketing | No Comments »

Dr. Adam Aronson, for Kids First Pediatric Partners, has an explainer, “Circumcision: A Parent’s Choice”. It’s predictable rather than what it should be. But given that there are countless versions of this same refusal to take the ethical stand, I highlight this one because it’s poorly framed in an instructive way.

Reasons Parents May Choose Circumcision
There are a variety of reasons why parents choose circumcision.

Medical benefits, including:

  • A markedly lower risk of acquiring HIV, the virus that causes AIDS.
  • A significantly lower risk of acquiring a number of other sexually transmitted infections (STIs), including genital herpes (HSV), human papilloma virus (HPV), and syphilis.
  • A slightly lower risk of urinary tract infections (UTIs). A circumcised infant boy has about a 1 in 1,000 chance of developing a UTI in the first year of life; an uncircumcised (sic) infant boy has about a 1 in 100 chance of developing a UTI in the first year of life.
  • A lower risk of getting cancer of the penis. However, this type of cancer is very rare in all males.
  • Prevention of foreskin infections.
  • Prevention of phimosis, a condition in uncircumcised (sic) that makes foreskin retraction impossible.
  • Easier genital hygiene.

These are stated as facts. I concede¹ them as facts for my purpose here, even though I think it’s critical to mention, for example, that the relative risk reduction for female-to-male HIV transmission applies to populations with high incidence of HIV and low circumcision rates, which doesn’t map to the HIV problem in the United States. Also, the absolute risk is tiny. Whatever. Yay, facts, I guess, because none of that justifies applying them to the normal, healthy foreskin of a child (i.e. parental choice).

But that isn’t the issue. This is:

Reasons Parents May Choose Not to Circumcise
The following are reasons why parents may choose NOT to have their son circumcised:

  • Fear of the risks. Complications are rare and usually minor but may include bleeding, infection, cutting the foreskin too short or too long, and improper healing.
  • Belief that the foreskin is needed. Some people feel the foreskin is needed to protect the tip of the penis. Without it, the tip of the penis may become irritated and cause the opening of the penis to become too small. This can cause urination problems that may need to be surgically corrected.
  • Belief it can affect sex. Some feel that circumcision makes the tip of the penis less sensitive, causing a decrease in sexual pleasure later in life.
  • Belief that proper hygiene can lower health risks. Boys can be taught proper hygiene that can lower their chances of getting infections, cancer of the penis, and STIs.

Parents “fear” the rare and usually minor risks, yet the potential benefits were presented as parents’ reasoned approach to risks rather than parents circumcising because they fear statistically-unlikely problems. This is especially odd since most of the potential problems used to justify non-therapeutic infant circumcision are even less likely to occur during the years parents are responsible for their child’s health.

Parents hold a “belief” that the foreskin is needed. They “feel” the foreskin protects the tip, as if circumcision removes only the foreskin around the tip of the boy’s penis. And the transition to the facts of irritation and possible meatal stenosis holds the stigma of “belief” rather than “reasons not to remove an individual’s normal, healthy foreskin without his consent”.

Parents may have a “belief” that circumcision can affect sex, even though this is a fact once the foreskin is gone. Changing form changes function. It doesn’t have to get to a change in sensitivity.

Parents trust in “belief” that proper hygiene² can lower health risks, which we know is a fact. It’s also our default expectation that parents properly care for every normal part of a child, except a boy’s foreskin, because that has a hygiene exception where surgery is somehow justifiable as a parental choice.

This frame appears over and over again. “Reasonable” people understand that circumcision provides important benefits that are “good”, as the Los Angeles Times Shareline demanded yesterday. It appears in almost every interview Dr. Douglas Diekema gave on behalf of the AAP or CDC in the last few years, such as when he said “If you talk to reasonable people about what the data shows… it’s real. …” Circumcision is designated as the rational approach. Parents who impose it are presented as more rational because they looked at facts, at science. Parents who respect their son’s normal, healthy body as they respect their daughter’s normal, healthy body are presented as emotional, anti-science, or “foreskin fetishists”. Their argument allegedly amounts to nothing more than “don’t hurt the babies”. They “believe” in spite of facts.

Here’s the first list again, processed through the second list’s filter:

Reasons Parents May Choose Circumcision

  • Fear of HIV, even though the absolute risk of female-to-male vaginal transmission in the United States is markedly low.
  • Belief that he will be at risk of other sexually transmitted infections (STIs), including genital herpes (HSV), human papilloma virus (HPV), and syphilis. Condoms protect significantly better against STIs, and a vaccine exists for HPV that is approved for males, as well.
  • Belief that the adhered, non-retractable foreskin could trap dirt, leading to a UTI. Some research suggests that infant circumcision causes at least as many UTIs as it prevents.
  • A belief that foreskins lead to cancer of the penis. However, this type of cancer is very rare in all males.
  • A belief that the foreskin can’t be cleaned sufficiently, leading to infections.
  • Belief that phimosis is more common than it is and can only be treated with circumcision. Steroid creams and manual stretching can often resolve non-retractable foreskin issues.
  • Fear of smegma. Males and females produce smegma. Regular bathing minimizes risk.

How does it look now?

Proponents of parental choice need to reconsider their support, for they are wrong. They must prioritize the facts of the boy’s (i.e. the patient’s) present, and how there is no problem in need of the most invasive solution. Science without ethics is a monstrosity posing as a reasoned set of facts. There is no defense for prioritizing fear of a statistically-unlikely future to imagine validity for parental choice for non-therapeutic genital cutting of children (male-only, “obviously”) now.

¹ I do not concede them as valid justifications. I’ve omitted the social and religious reasons sections from discussion. Potential medical benefits are insufficient to justify non-therapeutic child genital cutting. Social and/or religious reasons should obviously be recognized as particularly insufficient to justify proxy consent for (non-therapeutic) surgery.

² I do not concede this item as a fact, even for rhetorical purposes. “Easier” caters to the ignorant and lazy. This should be clear from Dr. Aronson’s last paragraph, “What If I Choose Not to Have My Son Circumcised?”.

… Keep in mind that the foreskin will not fully retract for several years and should never be forced. When your son is old enough, he can learn how to keep his penis clean just as he will learn to keep other parts of his body clean.

So, for the bulk – or all – of the time that parents will be primarily responsible for keeping their son’s genitals clean, it requires no extra work to clean an intact penis. This excuse deserves no credibility.


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 | 1 Comment »

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.