The AAP Discounts Its Patients’ Right to Physical Integrity

Posted: March 23rd, 2013 | Author: | Filed under: Ethics, FCD, Law, Logic, Parenting, Politics, Public Health, Science, STD, Surgery | No Comments »

In “Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision”, Morten Frisch, MD, PhD, et al (pdf) criticize the AAP’s revised policy statement on circumcision. In part, they state:

The most important criteria for the justification of medical procedures are necessity, cost-effectiveness, subsidiarity, proportionality, and consent. For preventive medical procedures, this means that the procedure must effectively lead to the prevention of a serious medical problem, that there is no less intrusive means of reaching the same goal, and that the risks of the procedure are proportional to the intended benefit. In addition, when performed in childhood, it needs to be clearly demonstrated that it is essential to perform the procedure before an age at which the individual can make a decision about the procedure for him or herself.

They raise many issues surrounding the AAP’s focus on UTIs, penile cancer, STDs, and HIV. They conclude that non-therapeutic circumcision “fails to meet the commonly accepted criteria for the justification of preventive medical procedures in children.” Even ignoring their critique of the applicability of the scientific studies involved in the AAP’s revised policy statement, they are convincing. Their ethical argument is powerful.

The response by the AAP’s Task Force on Circumcision is intriguing and bizarre. It’s intriguing because it raises potential issues with what Frisch et al wrote about the science. This section is worth discussing, but not by me. I see the points on both sides. It’s difficult for either to squeeze every helpful detail into a few pages. For this, I’ll leave it with my usual statement. I am willing to accept the claimed benefits, however faulty they may be. The ironclad ethical case against non-therapeutic child circumcision is no weaker if all of the AAP’s criticisms have full merit.

Its response is bizarre for the ethical issues the Task Force continues to dismiss and ignore.

First, responding to the claim that the Task Force suffered from cultural bias:

… Although that heterogeneity may lead to a more tolerant view toward circumcision in the United States than in Europe, the cultural “bias” in the United States is much more likely to be a neutral one than that found in Europe, where there is a clear bias against circumcision. …

That (claimed) neutrality is the problem in the AAP’s revised policy statement on male circumcision. They imagine that there is no right answer to this ethical question. Here, the physical integrity of a healthy child is surgically violated without his consent. The law recognizes a single correct answer for female minors on the same ethical question. The implicit conclusion that male minors possess a lesser right to their physical integrity than their sisters is indefensible. It doesn’t matter that potential benefits exist from circumcision. Frisch et al demonstrate this in analyzing the difference between consent and proxy consent for a non-therapeutic intervention.

The AAP continues its challenge:

… Yet, the commentary’s authors have, at no point, recognized that their own cultural bias may exist in equal, if not greater, measure than any cultural bias that might exist among the members of the AAP Task Force on Circumcision. If cultural bias influences the review of available evidence, then a culture that is comfortable with both the circumcised penis and the uncircumcised penis would seem predisposed to a more dispassionate analysis of the scientific literature than a culture with a bias that is either strongly opposed to circumcision or strongly in favor of it.

So, basically, the AAP’s Task Force is saying “I’m rubber, you’re glue”.

To the point, Frisch et al show that the cultural acceptability of circumcision is not a valid defense because there is a right answer to the ethical question involving this prophylactic surgical intervention on healthy children. The AAP missed the essential issue in its recommendation. The ongoing American experiment with circumcision is a reasonably-inferred explanation. Frisch et al emphasize the child in non-therapeutic child circumcision. The AAP continues to emphasize only circumcision, with the children being a distant abstract. That is the problem, regardless of the reason.

For the purpose of those paragraphs, I pretended that the AAP’s claim that the US is neutral on infant circumcision isn’t laughable nonsense. On the basis of individual opinions, I think we’re probably the fifty-fifty nation they imagine. Institutionally, both medically and politically, we are very much a pro-circumcision nation. The Task Force stated a truth, while missing it, in its Technical Report:

… Reasonable people may disagree, however, as to what is in the best interest of any individual patient or how the potential medical benefits and potential medical harms of circumcision should be weighed against each other.

The factually-unprovable statement in the Abstract that the “preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure” is the evidence that the AAP is not a pillar of neutrality on non-therapeutic male child circumcision. The Task Force thinks the subjectivity it mistakenly presents as a valid general conclusion in its Abstract may reasonably be taken into consideration for circumcising an individual by proxy consent. If they understood the ethical implications, they would acknowledge that it must only be taken into consideration by the individual for his own healthy body. The neutral position presents facts and lets the individual choose. The biased position lets someone else impose a permanent, unnecessary intervention for the individual.

The Task Force includes a section, Age at Circumcision, in which their argument is that many minors make their sexual debut before the age of majority and some of those people are irresponsible with regard to condoms. The Task Force argues these two facts render it acceptable for parents to make their son’s circumcision decision for him. It views parents through an ideal, rather than the reality of human decision-making where a child must live with the permanent consequences of an unnecessary decision. Individuals are just part of a statistic.

When the Task Force finally gets to the ethical issues, it whiffs again:

… The authors’ argument about the basic right to physical integrity is an important one, but it needs to be balanced by other considerations. The right to physical integrity is easier to defend in the context of a procedure that offers no potential benefit, but the assertion by Frisch et al of ‘no benefit’ is clearly contradicted by the published scientific peer-reviewed evidence. …

Because there are potential benefits, we may discard the supremacy of the basic human right to physical integrity for the healthy child? That’s ridiculous. They don’t say it directly, but their conclusion for parents making their son’s choice endorses it in reality. With this thinking, any number of extreme surgical interventions could be justified on a healthy child because they might offer some benefit at some point. We should at least research any possible intervention to make sure we’re not missing some benefit that could decrease some risk, if that really is an acceptable approach. Or we could be rational and set aside our long-held cultural acceptance of this unethical procedure, but that’s harder to defend than fear, I guess.

The second statement, the “assertion by Frisch et al of ‘no benefit'”, is not supported by my reading of their paper. They do not state there is ‘no benefit’ to circumcision. They question the strength of the benefits and their applicability to children, particularly because less intrusive methods to achieve these benefits are available. The Task Force builds a straw man instead of confronting the ethical issues.

Finally, the Task Force asserts the “right to grow up circumcised“:

Frisch et al appeal to the ethical precept “First, do no harm,” but they fail to recognize that in situations in which a preventive benefit exists, harm can also be done by failing to act. Whereas there are rare situations in which a male will be harmed by a circumcision procedure, …

I’m interrupting the excerpt to correct this inaccurate statement. Every circumcision inflicts harm, including loss of normal tissue and nerve endings, as well as scarring. Some circumcisions inflict more harm than expected or intended. The Task Force conflates intent and outcome.

… it is also true that some males will be harmed by not being circumcised. Simply because it is difficult to identify exactly which individuals have suffered a harm because they were not circumcised should not lead one to discount the very real harms that might befall some men by not being circumcised. …

I don’t discount the real harms some will experience from the risks in being alive with a normal human anatomy. I dismiss their relevance in this context. It’s a dumb standard for evaluating what may be done to a healthy child without his consent. Life can never be lived without risk. If a male is worried enough about the minimal risks posed by his foreskin, he can elect to be circumcised with his own informed consent. But the reverse is not true. A male who is circumcised at birth can’t recover his foreskin if he would not trade his foreskin¹ for the proposed benefits. Individual choice is the valid, superior ethical position.

Their conclusion:

… There is no easy answer to this issue ethically. Regardless of what decision is made on behalf of a young male, harm might [ed. note: will, if the decision is circumcision] result from that decision. That is precisely why the AAP task force members found that this decision properly remains with parents and that parents should have information about both potential benefits and potential harms as they make this decision for their child.

There is an easy answer to this issue ethically. Non-therapeutic genital cutting on a non-consenting male is unethical. It inflicts guaranteed harm to minimize already tiny risks. This is the same easy answer we draw for females. We know parents shouldn’t make this decision unless it is “necessary to the health of the person on whom it is performed” when the person on whom it is performed is female. We’ve legislated this knowledge. The right to physical integrity is easy to defend. The AAP has an ethical duty to defend it for all children, including males.

¹ Full quote from AAP Task Force on Circumcision member Dr. Douglas Diekema: “[Circumcision] does carry some risk and does involve the loss of the foreskin, which some men are angry about. But it does have medical benefit. Not everyone would trade that foreskin for that medical benefit.”


Argument from Ignorance and/or Hatred

Posted: October 31st, 2012 | Author: | Filed under: "Voluntary", Control, FGM, Politics, Religion | 2 Comments »

In a letter to the editor of the Standard-Examiner in Ogden, Utah, a reader attempts to make a point about Sharia Law. I’m not going to wade into the political aspect of this. But the reader makes an informative error. He writes:

When girls reach age 12 to 14 they are held down, naked, by usually their mothers or as many men that it takes to hold them down, as they cut their clitoris off. They say this helps to control them. Then the girl’s legs are wrapped together for 40 days so the wound can heal.

I could quibble, but this more or less sets up the issue. FGM is evil. But the reader loses his narrative in the next paragraph. He gets basic facts wrong that contribute to a mistaken distinction that doesn’t exist within the principles he aims to establish. (emphasis added)

They tell the little girls that this will make it more pleasurable for their husband when they get married while being denied any sexual pleasure themselves. This mutilation of the genitals makes it painful to have sex and extremely painful to bare children. Everyone knows that they have to be covered up head to toe and escorted by a male wherever they go, but I wonder if the American people know that it is OK to beat their wives by hand or by stick as needed. Or that they are forced to perform oral sex with their husbands, who have not been circumcised so the penis stinks due to the buildup of urine. If the woman complains the husband cuts off her nose.

The principles he implies are the basics. Females possess the rights to their bodily integrity and autonomy. They should be free from unnecessary harm without their consent. Cutting their healthy genitals violates them. It is bodily harm. They are mutilated.

The problem here is that the same rights exist for males. Non-therapeutic genital cutting on a non-consenting individual, not just the genital mutilation of girls, violates the principles involved, regardless of the extent. The husbands of these women are almost certainly circumcised. Their genitals are not cut to the extent that their wives’ genitals are cut. They are cut, though. I’m not aware of any cultures that cut females that don’t also cut males. (Please correct me if I’m wrong.) In Egypt male circumcision is practiced as a part of Islam.

The reader’s comment that the husbands are not circumcised would be bad enough on its own because it’s inaccurate. The additional “so the penis stinks due to the buildup of urine” is projection. It strives to distinguish forms of non-therapeutic genital cutting with an ignorant dismissal of basic hygiene. It seeks to reiterate a validity and desirability for male circumcision, without regard for the male’s preference. The issue the reader raises but fails to crystallize is the use of force.

Forcing genital mutilation on girls is wrong. Forcing wives to have any form of sex is wrong. That extends to males, as well, if the desire to protect females is to carry complete moral weight. Any system – whether political, cultural, or religious – that permits or encourages the use of force by one citizen against another citizen for any reason other than self-defense is illegitimate. The reader’s core point is correct. He should apply it as a universal to all people, not selectively as an instrument endorsing his own cultural relativism. (He is not unique in this, of course. Commonality doesn’t justify it.)


AAP Circumcision Policy – Flawed Ethics

Posted: September 12th, 2012 | Author: | Filed under: "Voluntary", Control, Ethics, FCD, HIV, Law, Logic, Media Marketing, Parenting, Politics, Public Health, Science, STD | 7 Comments »

Much has already been said on the flaws in the AAP’s revised policy statement on non-therapeutic male child circumcision. (Here’s an additional plug for the exceptional rebuttal by Brian D. Earp.) I want to comment directly on its recommendations and the ethical issues addressed – or unaddressed – in the technical report. First, from page 757:

The Task Force made the following recommendations:

  • Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it.
  • Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.

These two statements conflict. Stating that the benefits outweigh the risks is a judgment call based on subjective valuations of the various inputs. The task force recognizes this when acknowledging that some parents would value other considerations more than the AAP’s evaluation of the net effect. That same possible difference of opinion applies to the cost-benefit analysis itself, which should include actual costs (i.e. the foreskin) rather than just risks.

The AAP is stating that it’s possible to disagree with the task force, but only to an extent because it reviewed the data and drew a conclusion. That’s wrong because the evaluation requires subjective weightings rather than objective criteria. It’s one thing to question the possible benefits altogether, as some do. It’s also possible to accept the potential benefits while not valuing them more than the costs involved. All individual tastes and preferences are unique. AAP Circumcision Task Force member Dr. Douglas Diekema said as much prior to the release of the revised policy statement. Why is that not reflected here in place of this incorrect statement that the benefits definitively outweigh the risks (and the unmentioned costs/harms)?

Further discrediting its recommendation on this, the ethics section (Pg. 759) states:

… Reasonable people may disagree, however, as to what is in the best interest of any individual patient or how the potential medical benefits and potential medical harms of circumcision should be weighed against each other.

The highlighted statement is the ethical argument. This accurate statement contradicts the conclusion the AAP presents that the potential benefits definitively outweigh the risks it considered. It is more relevant in the context of what the individual being circumcised might value. How will he – rather than his parents – want the benefits, risks, and costs weighed against each other for his normal, healthy foreskin? That’s the ethical core that the AAP Task Force sidestepped. Its recommendation for proxy consent for non-therapeutic circumcision is indefensible.

Moving on to the Ethical Issues section (pp. 758-760):

As a general rule, minors in the United States are not considered competent to provide legally binding consent regarding their health care, and parents or guardians are empowered to make health care decisions on their behalf.9 In most situations, parents are granted wide latitude in terms of the decisions they make on behalf of their children, and the law has respected those decisions except where they are clearly contrary to the best interests of the child or place the child’s health, well-being, or life at significant risk of serious harm.10

Sure. But that doesn’t support non-therapeutic male child circumcision. Proxy consent for permanent, amputative surgery must require something approaching objective need. Legally, we already require this for non-therapeutic genital cutting on female minors, including that which is analogous to or less harmful than a typical male circumcision. The comparison to be made for non-therapeutic male circumcision is whether or not parents are given this same non-therapeutic, cultural latitude in cutting the genitals of their daughters. They are not, which demonstrates that it shouldn’t be about the parents but about the child.

(a) Except as provided in subsection (b), whoever knowingly circumcises, excises, or infibulates the whole or any part of the labia majora or labia minora or clitoris of another person who has not attained the age of 18 years …

Subsection (b) establishes that only therapeutic genital cutting is legal for female minors. Subsection (c) rejects all parental preferences, whether cultural or religious, for non-therapeutic genital cutting on their daughters. It’s improper for the AAP Task Force to treat non-therapeutic male child circumcision as if it’s just a health care decision. It’s unlike any other decision we allow. If nothing else, circumcision guarantees (i.e. “significant risk”) the child’s normal, healthy foreskin will be removed forever (i.e. “serious harm”). Do male minors ever become reasonable people who may disagree about the weighting of the benefits and risks?

Revisiting “reasonable people may disagree”:

Parents and physicians each have an ethical duty to the child to attempt to secure the child’s best interest and well-being.11 Reasonable people may disagree, however, as to what is in the best interest of any individual patient or how the potential medical benefits and potential medical harms of circumcision should be weighed against each other. This situation is further complicated by the fact that there are social, cultural, religious, and familial benefits and harms to be considered as well.12 It is reasonable to take these nonmedical benefits and harms for an individual into consideration when making a decision about circumcision.13

It is not reasonable. The individual who must live with the permanent consequences of the decision, if the decision is to circumcise, is not the person taking these non-medical benefits and harms into consideration. (Here, based on my earlier excerpt from this paragraph, benefits such as a reduced risk of heterosexually-acquired HIV should be evaluated as non-medical because they are a non-therapeutic justification for surgical intervention via proxy consent. Or remedy my rebuttal to “these medical benefits, non-medical benefits, and harms” if my precision focused on the lack of need irritates.)

In footnote 13, which is Diekema’s “ethics” perspective on Boldt v. Boldt, he concludes:

(3) Absent a significant medical indication, circumcision should not be performed on older children and adolescents in the face of dissent or less than enthusiastic assent.

This is important. Infants can’t consent, of course, but there is no reason that an inability to consent should be construed as a “yes” in favor of his parents’ preferences. Not even benefits that reasonable people may determine do not outweigh the risks (and costs). From the Ethical Issues section of the policy statement technical report:

Parents may wish to consider whether the benefits of the procedure can be attained in equal measure if the procedure is delayed until the child is of sufficient age to provide his own informed consent. These interests include the medical benefits; the cultural and religious implications of being circumcised; and the fact that the procedure has the least surgical risk and the greatest accumulated health benefits if performed during the newborn period. Newborn males who are not circumcised at birth are much less likely to elect circumcision in adolescence or early adulthood. Parents who are considering deferring circumcision should be explicitly informed that circumcision performed later in life has increased risks and costs. Furthermore, deferral of the procedure also requires longer healing time than if performed during the newborn period and requires sexual abstinence during healing. Those who are already sexually active by the time they have the procedure lose some opportunities for the protective benefit against sexually transmitted infection (STI) acquisition, including HIV; moreover, there is the risk of acquiring an STI if the individual is sexually active during the healing process. (See the section entitled Sexually Transmitted Diseases, Including HIV.)

First, note that it references a section on STDs, including HIV. Condoms are a cheaper, ethical way of achieving the same benefits and in greater than equal measure. They’re also still necessary after circumcision to prevent STDs, including heterosexually-acquired HIV. Yet, the word condom appears¹ zero times in the body of the technical report. Why?

The same applies to the other benefits, or there are safe, effective, non-invasive treatments available. It’s also reasonable to infer that, since people may disagree based on their preferences for whether the benefits outweigh the risks, people may also differ on whether the cited gains from infant circumcision rather than voluntary, adult circumcision are worth the trade-offs of their foreskin and their choice. The “greatest accumulated health benefits” isn’t enough to justify circumcising the individual who will not want to be circumcised.

The most crucial sentence in that excerpt is the third. Males left with their normal genitals are less likely to elect (or need) circumcision. This is too often portrayed as something akin to weakness or cowardice in the autonomous male, for which parents can be the brave, responsible decision-maker. (e.g. Brian Morris et al.) That’s a bad framing device. Instead, this unwillingness (i.e. less likely) is the most powerful indicator that males left with their foreskin value something more than being circumcised. Even if that is merely a desire to avoid the (perceived) pain of the surgery, it is proof of their preference against being circumcised. It is not better to guarantee that pain by forcing it on them in infancy. The typical defense is that they won’t remember it, which is so ridiculous that it could justify any intervention. As AAP Task Force member and bioethicist Douglas Diekema said, “Not everyone would trade that foreskin for that medical benefit.” If the AAP had reflected that view in its recommendations, the revised policy statement could’ve been ethical.

For the remaining sentences, parents who are considering deferring circumcision should be explicitly informed that circumcision performed later in life has a very low likelihood of being necessary. Why leave this point out to focus only on one side of the equation if parents should be fully informed? It shouldn’t be included as an abused throwaway in a technical report most parents will never know exists.

In cases such as the decision to perform a circumcision in the newborn period (where there is reasonable disagreement about the balance between medical benefits and harms, where there are nonmedical benefits and harms that can result from a decision on whether to perform the procedure, and where the procedure is not essential to the child’s immediate well-being), the parents should determine what is in the best interest of the child. In the pluralistic society of the United States, where parents are afforded wide authority for determining what constitutes appropriate child-rearing and child welfare, it is legitimate for the parents to take into account their own cultural, religious, and ethnic traditions, in addition to medical factors, when making this choice.11

It is not legitimate. The Task Force’s own words demonstrate that it’s possible for the individual male to not value circumcision. He is in his parents’ care for 18 years. (Per Diekema’s recommendation, his parents may be able to choose non-therapeutic circumcision for only a few of those years.) He will then be an autonomous adult for what will likely be another 40 to 80 years. What will he believe is in his best interest about his normal body for that time period? If his parents circumcise him, he will never be autonomous on this question. (As his sister(s) will be by law, contra the absurd idea that parents should be afforded wide authority to determine what constitutes his best interest forever.)

This decision involves informed proxy consent, not informed consent. For this, non-therapeutic circumcision, there is no reasonable disagreement about the lack of need. What is in the child’s best interest is to not undergo unnecessary surgery for reasons he may not value. He can choose it later, or his parents can choose it should genuine medical need arise while he remains their responsibility. He can’t unchoose it once it’s imposed.

The technical report does not support the AAP’s recommendations because it contains omissions and contradictions. Both the technical report and the condensed versions are irresponsible documentd that will perpetuate the violation of the bodies and rights of newborn males. They should be retracted.

¹ It appears once in a footnote as part of the title of a source.


Revised Chart – AAP and Declining Circumcision Rates

Posted: September 12th, 2012 | Author: | Filed under: Ethics, Media Marketing, Politics, Public Health | No Comments »

In the AAP’s technical report supporting its revised policy statement on non-therapeutic male child circumcision, there is a graph depicting the recent trend in circumcision rates, as shown in three studies. The graph is on page 759. Here it is:

As Hugh notes¹ in his annotated version (pdf):

This chart suppresses 100%, making a near 50:50 split look like a large majority.

I edited the original graph to add the missing 30%. (I copied the the bars covering thirty percent and added them above the seventy percent marker.) It provides a different perspective on the current rate.

The difference isn’t huge, and is hardly the most compelling point against the AAP statement. (Neither is the missing 71-100% above.) But it’s difficult to accept that the space saved by stopping at 70% is an acceptable trade-off for the flawed perspective the original chart could create.

¹ As he also points out, the chart begins in 1999. This is not necessarily an egregious decision because they’re relying on studies that look at that time period. Data for the years and decades prior to this is available (pdf), of course, and shows a larger decline in the newborn circumcision rate over the last few decades.


The New Marketing in Action

Posted: September 5th, 2012 | Author: | Filed under: "Voluntary", Control, Ethics, HIV, Politics, Public Health | 1 Comment »

Last month I showed that the marketing for circumcision had changed again to eliminate any remaining concern for either voluntary or adult. Voluntary, adult male circumcision had been rebranded down to “safe male circumcision”. Here is the inevitable goal being realized in Botswana. Babies to be circumcised:

As a long term plan to fight the HIV/AIDS spread the Ministry of Health will now introduce a Safe Male Circumcision (SMC) programme targeted at male babies and infants. In the past few years the government has been preaching SMC to males who are in sexually active ages.

“Towards the end of this year we want to enrol babies in the SMC programme and parents will be sensitised on the programme and its procedures. We have realised that targeting sexually active aged men and youth is not enough; we should have a long term vision for our strategies; targeting babies will result in the country having less people at risk of being infected with the virus in the next 15 to 20 years,” [Conrad Ntsuape, the National SMC Coordinator in the Ministry of Health] said.

When public health officials say voluntary or adult, they never mean voluntary or adult. They are “targeting” and “enrolling” infant males. It’s propaganda.

Also notice the fallacy that circumcising infants will result in fewer people at risk of being infected with HIV in the next 15 to 20 years. That is inaccurate, and a warning sign that they do not understand what they are doing. Circumcising infants will (allegedly) result in more males with a reduced risk of becoming HIV infected during vaginal intercourse with an HIV-positive female. Each male still retains a risk of infection, and without other (more effective) changes, including consistent condom use, men – and their partners – will still become infected. Spreading this incorrect understanding is an effective way to continue the spread of HIV.

Relevant to this problem with marketing:

Media were singled out as not playing a visible role in relaying the message on SMC. Beauty Gakale, the SMC Regional Coordinator said SMC should be given wide coverage to avoid confusion and misconceptions about it in the public. “Media, especially private media have been less active in relaying the SMC message and it is high time they played a role in this. We are also urging political leaders to play their role by encouraging men to undergo the SMC. ”

Public officials should worry about their own mistakes before demanding that media assist them in pushing propaganda. For example:

Asked why the advantages of the SMC are communicated to the public while the disadvantages are hardly discussed, Dr. [Adrienne] Musiige said SMC is like any other surgery and can be susceptible to infection if not well managed.

That didn’t answer the question.


AAP Task Force Member Douglas Diekama Maligns Circumcision Opponents

Posted: August 30th, 2012 | Author: | Filed under: "Voluntary", Ethics, FCD, Logic, Politics, Public Health, Science | 2 Comments »

The Washington Post’s parenting blog has a new post, ‘Intactivists’ furious at new AAP circumcision policy, that contains a misdirection from Dr. Douglas Diekema. After quoting Ronald Goldman and a few commenters to an earlier post, this:

AAP officials expected such a reaction.

“For individuals who have decided that circumcision is wrong, no amount or quality of data will put these questions to rest,” Douglas Diekema, who served on the AAP task force that wrote the report, told me last week when I asked him about potential pushback.

Diekema implies that people who are against circumcision simply haven’t correctly considered the data, which means “reached his personal conclusion”. He implies that opponents have made a demonstrable error in judgment. This is nonsense. It’s consistent to accept every single piece of data the AAP considered, and to ignore the relevant information the AAP explicitly ignored in its consideration, yet reach the conclusion that non-therapeutic infant circumcision is unjustified medically (and ethically), contra the AAP’s biased and flawed statement. To quote Douglas Diekema himself:

… But it does have medical benefit. Not everyone would trade that foreskin for that medical benefit. …

No kidding. That’s the ethical issue, but it also shows that the benefits do not outweigh the risks for every individual. Diekema is engaging in propaganda, facilitated by The Washington Post. Both aspects of that are inexcusable.

I’ve sent an e-mail to the Washington Post blogger, Janice D’Arcy, asking for comment on Diekema’s problematic quote. I will update if I receive a response.


Brian D. Earp on the AAP’s Flawed Circumcision Policy Statement

Posted: August 30th, 2012 | Author: | Filed under: "Voluntary", Ethics, HIV, HPV, Logic, Politics, Public Health, Science, STD | No Comments »

If you read only one analysis on the AAP’s revised policy statement on infant circumcision, make it this fantastic deconstruction by Brian D. Earp. It’s almost too perfect to excerpt. This is a great sample, but his entire post is required reading.

Here they depart from their 1999 statement in asserting that (1) the benefits of the surgery definitively outweigh the risks and costs and (2) that it is therefore justifiable to perform the operation without the informed consent of the patient. This does not follow. In medical ethics, the risk/benefit rule was devised for therapeutic procedures aimed at treating an extant pathological condition, and for minor prophylactic interventions such as vaccination. It has no relevance to nonessential amputative surgery, especially when it involves the painful removal of healthy, functional erogenous tissue from the genitals, and when safer, more effective substitute strategies exist for achieving the same ends.

You may be surprised to learn that the word “condom” does not appear even once in the 28 page AAP report.

In making their risk/benefit calculations, then, the AAP simply leaves out a critical bulk of factors relevant to the equation, including the existence of a range of proven healthcare tools like condoms, vaccines (including an effective HPV vaccine), and antibiotics. If they had bothered to consider human rights and bodily integrity issues, the function of the foreskin, its value to the individual, and his possible wishes in later life, as well, their computations would quite plainly yield a very different answer.

Seriously, it’s worth the time. And share it far and wide.


The AAP Worsens Its Flawed Circumcision Position

Posted: August 27th, 2012 | Author: | Filed under: "Voluntary", Ethics, FCD, First Amendment, Hygiene, Law, Logic, Media Marketing, Mission, Pain, Parenting, Politics, Public Health, Science, STD | 2 Comments »

A lot has already been said about the AAP’s revised policy statement on non-therapeutic circumcision on non-consenting male children.

More will be said today and beyond. Much of it will be uncritical regurgitations of the AAP’s revision by news organizations. There will also be analysis from those who recognize and highlight the glaring deficincies and oversights in the policy. I expect to contribute my own thoughts. For now, I’ll highlight one key aspect from my initial read-through before going into what I think is a more important consideration to this apparent-but-not-really temporary setback.

The short version of the statement ends with this (emphasis added):

Parents ultimately should decide whether circumcision is in the best interests of their male child. They will need to weigh medical information in the context of their own religious, ethical, and cultural beliefs and practices. The medical benefits alone may not outweigh these other considerations for individual families.

That’s so close to the ethical stance. Remove families and focus on the individual and it would be ethical¹.

The way the promoted portion of the new “finding” within the revised statement differs from this conclusion is the key takeaway to challenge the supposed change from the AAP, which is really more-or-less just an exercise in urging politicians to permit circumcision on Medicaid. Here, the AAP demonstrates that its evaluation of the net benefit, that possible benefits outweigh the risks, is subjective and determined only by individuals. This directly contradicts the supposed proof based on their review of research that the potential benefits outweigh the risks (and the costs – the direct harm in every case – that they ignore). We should repeatedly emphasize that as often as necessary.

My concern is that we’ll get stuck in this low-level, short-term portion of the larger debate. It’s clear from European medical associations and courts that the eventual destination is public policy against non-therapeutic circumcision. The AAP and American society, in general, are (inexcusably) behind. But both will get there. Activists for the rights of children can make that happen sooner than it otherwise might happen.

The key is that we must give people the opportunity to save face, to avoid digging in to protect their egos. The problem is their stance, not necessarily their character. It should be obvious to them that their stance is incorrect. It isn’t. To address that, do we want to express an irrelevant, limited sense of superiority or convince others that we’re correct because facts and ethics demonstrate the case we’re making? If we impugn their motives and/or character by choosing the former, we may extend the period during which this policy statement stands or encourage people who can be influenced either way to choose the inferior stance of the AAP.

Edit note: I changed “it’s” to “their stance” to avoid possible confusion.

¹ The existing societal view treats certain basic human rights – for boys only – as a buffet from which parents may pick and choose for their own reasons. This is the problem merely expressed within the AAP’s policy statement.


Infant Male Circumcision and Current Human Rights Disparities

Posted: August 21st, 2012 | Author: | Filed under: Ethics, FCD, HIV, HPV, Logic, Politics, Public Health | 1 Comment »

Another focused post for a story on which I’ll have more to say.

In a study published Monday in the Archives of Pediatric and Adolescent Medicine, a team of economists and epidemiologists estimated that every circumcision not performed would lead to significant increases in lifetime medical expenses to treat sexually transmitted diseases and related cancers — increases that far surpass the costs associated with the procedure.

I strongly suspect the study is flawed because it makes estimates. I’ll withhold further comment until I know more. For now, there’s enough to discredit the embarrassingly incomplete approach used to justify the study and its estimates.

That sentiment [that Medicaid should cover non-therapeutic child circumcision] was echoed in an editorial accompanying the study. UCLA health economist Arleen Leibowitz wrote that by failing to require states to cover circumcision in Medicaid plans, the U.S. reinforces healthcare disparities.

“If we don’t give poor parents the opportunity to make this choice, we’re discriminating against their health in the future,” she said in an interview. “If something is better for health and saves money, why shouldn’t we do it? Or at least, why shouldn’t we allow parents the option to choose it?”

We shouldn’t do it or allow it because non-therapeutic genital cutting on a non-consenting child is unethical. Male circumcision on a healthy child violates his basic human rights to bodily integrity and self-determination. It is indefensible, even if it’s possibly “better” for his health in someone else’s subjective evaluation or because it saves money when individuals are considered statistics rather than human beings with their own rights and preferences.

The abstract makes it clear the study is speculative. Yet, we already have rights-based law for females without absurd exemptions we refuse to touch for males, so the idea that rights trump speculative benefits isn’t foreign. The ability to do something or to possibly achieve some population-level result without concern for the individuals involved cannot – must not – be viewed in a bubble that contains only the factors one is interested in (e.g. male circumcision is currently practiced, so it’s acceptable).

There are no doubt many non-therapeutic surgeries we could perform on children that might result in some decreased prevalence of disease x, y, or z. Infant mastectomies to remove breast bud tissue might reduce the risk of breast cancer. Shouldn’t we study that, at least, since it might reduce cancer? Reducing cancer is “good”, whatever the means, right? No one is foolish enough (yet?) to think such a thing, which highlights the flaw in thinking by those making excuses for circumcision, such as Ms. Leibowitz here. Society should stop ignoring the costs to the individual who must bear the outcome of the decision. Ignoring them is unacceptable. The ethics of circumcision are not divisible from any other basic human rights consideration or proper medical analysis based on therapeutic need, or lack thereof.

Finally, that non-poor families can afford to violate their children’s sons’ rights is not a reason to use taxpayer funds to let poor parents violate their children’s sons’ rights. That’s a political question rather than a medical question. It is inexcusable to sacrifice the bodies of male children (only!) because we’re too cowardly to honestly evaluate the mistake of non-therapeutic circumcision on non-consenting individuals. This is the same idiotic approach Dr. Edgar Schoen pushed in his 2005 propaganda book, “Ed Schoen, MD on Circumcision”. Somehow, not using public funds to violate a child’s body and rights is discrimination. It isn’t because circumcision is not a valid parental choice. UCLA health economist Arleen Leibowitz is wrong.

None of this is a surprise, based on the editorial by Ms. Leibowitz and Katherine Desmond, “Infant Male Circumcision and Future Health Disparities”. The first two sentences reveal so much.

The health benefits of male circumcision (MC) have been extensively documented in observational studies and by randomized controlled trials in Africa showing that MC reduces heterosexual transmission of human immunodeficiency virus (HIV) infection from women to men by 55% to 76% …

The trials showed that voluntary, adult male circumcision reduces female-to-male HIV transmission in high risk populations with a heterosexual epidemic and a low rate of circumcision among adult males. That’s quite different, since it doesn’t describe the United States. It also fails to describe the circumcision they’re advocating. Children are not adult volunteers. That’s the ethical flaw in their analysis.

… and provides significant protection against human papillomavirus infection. …

Gardasil is approved for girls and boys. Circumcision is unnecessary for this possible benefit, as it is for nearly every possible benefit.

… Male circumcision is negatively associated with prostate cancer in men and with cervical cancer in female partners of men infected with human papillomavirus.

Negatively associated. Correlation is not causation. The study’s authors acknowledged this when they stated that it was an observational study. “Negatively associated” is not sufficient.


Flawed Circumcision Defense: Wesley J. Smith

Posted: August 10th, 2012 | Author: | Filed under: Ethics, FCD, First Amendment, Law, Parenting, Politics | 2 Comments »

The Norwegian ombudsman for children’s rights recently stated about ritual circumcision:

[Pediatrician] Dr. Anne Lindboe told the newspaper Vart Land last month that circumcision in boys was a violation of a person’s right to decide over his own body. “Muslim and Jewish children are entitled to the same protection as all other children,“ she said. She added that the practice caused unnecessary pain and was medically unbeneficial.

The children’s ombudsman is an independent governmental institution entrusted with safeguarding the rights of minors.

Yes. Her statement is similar to the ruling from Cologne that non-therapeutic child circumcision violates the child’s rights to bodily integrity and self-determination.

That logical statement is meeting resistance. Over at Secondhand Smoke, which claims to be a “24/7 Seminar on Bioethics and the Importance of Being Human”, Wesley Smith revealed that he doesn’t much understand how non-therapeutic circumcision involves bioethics¹ or that having a normal anatomical body part is part of being human. In response to Dr. Lindboe, he wrote:

First, circumcision after the start of puberty is far more risky and complicated than infant circumcision. …

Perhaps. It’s also unlikely to be necessary later. The real consideration is between guaranteed pain and harm from the unnecessary surgery on an infant and it being riskier and more complicated as an adult in the unlikely event it’s needed. If a male chooses non-therapeutic circumcision, ritual or not, as an adult, he is expressing that he values the possible benefits more than the risks. Consent is the issue. (There are also advantages to waiting, such as not needing to forcibly separate the foreskin from the glans and having a larger penis to better measure how much skin to remove.)

He continues:

… But more fundamentally, religious liberty is one of the world’s most important freedoms. …

Yes, but there are other freedoms, such as the rights to bodily integrity and self-determination. They’re also important. And children possess their own individual right to religious freedom.

… For you secularists who don’t care, it seems to me that means that you only care about liberties you want for yourselves–which isn’t freedom at all.

First, that’s ad hominem. Second, he’s wrong. It’s possible to care about many freedoms at the same time, and for all people equally, including children. It’s possible for secularists to care about religious liberty possessed by parents while recognizing the ethical flaws inherent in non-therapeutic child circumcision that place the surgery outside the scope of individual religious liberty for parents.

The attack he perceives is misunderstood. (See also.) An attack on religious freedom would require an effort to prohibit religious circumcision, full stop. The current facts have been presented that way, which is incorrect (for whatever reason that misrepresentation occurs). The effort here is to prohibit non-therapeutic circumcision on a child who can’t consent. It aims to leave each child with his choice. He retains his right to have himself circumcised for religious (and/or non-religious) reasons. He may exercise his freedom of religion rather than having it exercised for him by his parents.

This necessary change will require religion to accommodate a different understanding of religion’s interaction with individual civil rights. That can and should be debated. As evidenced by Mr. Smith’s words, he hasn’t engaged that debate yet.

But if we believe that religious liberty is fundamental–it is, after all, a core part of the Universal Declaration on Human rights–then Jews and Muslims have a right to circumcise their children. [ed. note: males only?] Indeed, it is a religious imperative. …

It’s consistent to believe that religious liberty is fundamental and that no one has a right to circumcise their healthy children. It may be an imperative, but that alone grants no right.

Here is another core part of the Universal Declaration of Human Rights (emphasis added):

Article 1.

  • All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood.

Article 2.

  • Everyone is entitled to all the rights and freedoms set forth in this Declaration, without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status. Furthermore, no distinction shall be made on the basis of the political, jurisdictional or international status of the country or territory to which a person belongs, whether it be independent, trust, non-self-governing or under any other limitation of sovereignty.

Article 3.

  • Everyone has the right to life, liberty and security of person.

Mr. Smith writes as if other rights aren’t implicated by the exercise of religious freedom. The rights expressed earlier, and clearly, in the Universal Declaration of Human Rights are strikingly similar to those expressed by the District Court of Cologne and Dr. Anne Lindboe. It is clear that he is wrong rather than those with whom he disagrees.

To close he cites this essay by David P. Goldman, which deserves a post of its own rather than an analysis here. After the excerpt, Smith writes:

It doesn’t matter whether the Norway ombudsman or any of us agree. Circumcision is a sacred duty for Jews, a rite that brings the infant into the community. I assume the same is true for Muslims. In the name of freedom, government must leave it alone.

In the name of freedom, a legitimate government must protect the rights of all citizens equally. Because non-therapeutic child circumcision violates various rights of the child and inflicts permanent physical harm in every instance, prohibition is the only means to promote individual freedom. That is the proper role of government.

¹ The issue is more complicated than parental intent or imperative because there are competing rights. It’s further complicated because very few advocates of circumcision acknowledge what the surgery does to the (healthy) child.