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.
… 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.”