Flawed Circumcision Defense: Waxman, Lowey, Berman, et al.

Twenty members of Congress sent a letter (PDF) to German Ambassador to the United States Peter Ammon. It’s a standard pro-circumcision talking points effort without any thought and without any acknowledgement that a (better) counter-argument exists. It’s the view of people living in a fantasy world. From the press release (emphasis added):

The letter, which was sent to German Ambassador to the United States Peter Ammon, objects to a June 26, 2012 decision in the District Court of Cologne as an affront to religious freedom because Jews and Muslims consider circumcision a fundamental rite of passage and affirmation of faith. …

It should be an affront based on objective criteria. In addition to the issue being a fundamental rite, circumcision is harmful to the recipient in objective ways. Prohibiting its imposition on a non-consenting individual (e.g. a child) would be an affront if the second issue were not involved. It is. This is an issue of competing rights. The District Court of Cologne ruled on that basis. These members of Congress, incorrectly meddling in the legal and policy affairs of another country, do not address the court’s ruling in their letter. They do not engage the facts.

For example, the press release concludes:

“A not so veiled assault on tenets central to religious expression is underway in Europe’s courts and legislatures,” added Rep. Berman. “We must let it be known to our friends in a clear and unequivocal voice that such measures are harmful assaults on religious freedom and should not continue.”

An attempt to regulate an activity is a “harmful assault” on an idea. I can accept that as a possibility, although the idea can’t be injured. It isn’t happening with a prohibition on non-therapeutic child circumcision. There is no assault on a valid freedom, just a child being injured during a non-therapeutic surgery. That is the only harmful assault involved. The Representatives are pushing empty platitudes as public policy at the expense of the rights of citizens.

For the letter itself, it’s linked above. I urge everyone to write a letter in response, especially if one of the twenty members is your representative. But we must remember to be respectful. Stick to the ideas. Do not engage in ad hominem or insinuation based on superficial factors. Focus on their words and how they contradict logic and equal human rights.

That Word Doesn’t Mean What Secretary Clinton Thinks It Means

October 1, 2015 update: I changed the word “condemnable” to “commendable” to reflect the intended meaning of a sentence. Additionally, the link to Secretary Clinton’s comments is now here.

The United States government encourages and funds circumcisions. It shouldn’t, of course, if we’re to adhere to the basic principles of human rights. (We don’t on this.) But it shouldn’t be promoted with lies. U.S. Secretary of State Hillary Clinton spoke yesterday at the 2012 International AIDS Conference. (emphasis added)

As of last fall, every agency in the United States Government involved in this effort is working together to get us on that path to an AIDS-free generation. We’re focusing on what we call combination prevention. Our strategy includes condoms, counseling and testing, and places special emphasis on three other interventions: treatment as prevention, voluntary medical [sic] male circumcision, and stopping the transmission of HIV from mothers to children.

Any familiarity with this subject provides a spoiler alert on what voluntary really means. Sure enough, shortly after that paragraph:

On male circumcision, we’ve supported more than 400,000 procedures since last December alone. And I’m pleased to announce that PEPFAR will provide an additional $40 million to support South Africa’s plans to provide voluntary [sic] medical [sic] circumcisions for almost half a million boys and men in the coming year. (Applause.) You know and we want the world to know that this procedure reduces the risk of female-to-male transmission by more than 60 percent and for the rest of the man’s life, so the impact can be phenomenal.

In Kenya and Tanzania, mothers asked for circumcision campaigns during school vacations so their teenage sons could participate. …

Voluntary circumcision requires the consent of the circumcised. Consent from anyone else for non-therapeutic circumcision is unethical.

And, no, it isn’t “medical” circumcision. It’s medicalized circumcision, which merely indicates that it’s performed in a modern, sterile operating theater. That is commendable in its limited focus, but it is not enough to render the non-therapeutic surgery ethical. Consent is also necessary. The perceived benefit of a reduced risk of female-to-male HIV transmission is a speculative pursuit and may not be necessary or desired by the individual.

Reading the Cologne Court’s Words

Since the recent ruling against non-therapeutic child circumcision by the Cologne district court, many have spoken out against it and claimed various and potentially extreme results that will flow from it. Some of these complaints are legitimate. As I previously wrote, there are issues offered by proponents of ritual child circumcision that deserve to be taken seriously. Asking people to let go of something they intensely value is asking them to bear costs, even if it should be clear that avoiding objective harm to the child must be stressed more. (That post is coming.)

Still, what I haven’t seen yet is the opposite view. I haven’t seen a single example of someone who supports legally-protected ritual child circumcision accurately acknowledge the court’s ruling as it was written, rather than using a selective reading, to defend the practice. (If someone has seen an example of a proper acknowledgement, please link it in the comments.) The closest I’ve seen comes from Chief Rabbi Lord Sacks, but he only built and defeated a straw man. Near his conclusion, he wrote:

That is what the court in Cologne has done. It has declared that circumcision is an assault on the rights of the child since it is performed without his consent. It ignored the fact that if this is true, teaching children to speak German, sending them to school and vaccinating them against illness are all assaults against the rights of the child since they are done without consent. The court’s judgement was tendentious, foolish and has set a dangerous precedent.

The issue of consent is only part of the court’s ruling. The child’s lack of consent factored because of what was being done to him. The court evaluated the act first. From an English translation of the ruling, found here:

… since the parents’ right to religious upbringing of their children, when weighed against the right of the child to physical integrity and to self-determination, has no priority, and consequently their consent to the circumcision conflicts with the child’s best interests. …

Circumcision violates the child’s (right to) physical integrity. Consequently, parental consent conflicts with the child’s rights, including his right to consent or to refuse. Contrary to Chief Rabbi Lord Sacks’ statement, the court did not imply parenting is now illegal. It made the necessary distinction to limit the ruling to non-therapeutic child circumcision.

… There was consent by the parents, but this was not capable of justifying the commission of the elements of bodily harm.

And:

… The parents’ fundamental rights under Article 4 (1), 6 (2) of the Basic Law (Grundgesetz, GG) in turn are limited by the fundamental right of the child to physical integrity and self-determination under Article 2 (1) and (2) sentence 1 GG. …

There are two rights involved. The right to physical integrity and the right to self-determination (i.e. consent). A complete attempt at a rebuttal requires acknowledging both.

An insufficient response such as that by Chief Rabbi Lord Sacks is not unique. Consider:

Muslim leaders joined the Jewish groups in their condemnation of the ruling. Ali Demir, chairman of the Islamic Religious Community in Germany, described circumcision as “a harmless procedure that has thousands of years of tradition and a high symbolic value.

There are also Christian (and probably secular) advocates who mistakenly defend circumcision as a parental right based on, but not limited to, their religious freedom. However, they all ignore, minimize, or fail to understand that circumcision, like all surgery, is not physically harmless to the child.

As the court stated, “the child’s body is permanently and irreparably changed by the circumcision.” Harm and its link to consent are the issues. Circumcision¹ inflicts harm, despite the presumed good intentions of parents. Only the individual directly affected can evaluate whether or not this objective physical harm is good, bad, or neutral for himself, permanently. Only he can decide whether or not he consents to this intrusion on his physical integrity. That is what the court ruled, not the convenient straw men floating around as a defense against the equal rights of children.

¹ Here I refer only to ritual and non-ritual non-therapeutic circumcision. Proxy consent for therapeutic circumcision requires further analysis and can be justified, although it also inflicts harm.

More on the Fallacy of VMMC: Infant Volunteers

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

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

Providing VMMC Services

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

Costing and Impact Summary

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

The key policy topics addressed by the model are:

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

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

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

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

Medical Male Circumcision

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

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

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

4.2.2 Voluntary medical male circumcision (VMMC)

Evidence

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

Program Implementation

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

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

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

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

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

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

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

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

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

**********

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

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

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

Politics: Legitimate and Illegitimate Medicine

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

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

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

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

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

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

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

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

Link via The Agitator.