Category: Public Health

Good Riddance to PrePex and Circ MedTech

I’ve written numerous times about PrePex in the past decade. (See: here, here, here, here, and here.) Generally the context involved an advertisement masquerading as journalism, with the source’s reliance on PrePex’s claim that it was non-surgical. As I said in my first post, the ability to limit bleeding does not mean it is non-surgical. Foreskin removal is surgical. Facts weren’t refuted just because the device’s manufacturer said so. “Non-surgical” was always a useful lie.

Now we know the truth.

… After beginning with great success in Africa, a series of events finally led to the company’s closure recently – after 10 years of operations. TheMarker has investigated what happened, using documents and interviews with people from the company, and has discovered that the PrePex device, which was meant to help prevent AIDS, was linked to a number of cases of death from tetanus in Africa.

Removing body parts isn’t risk-free. This shows the tendency of public health campaigners to sell lofty dreams without emphasizing risks and costs. “With this one special action, you can improve your life!” If there’s a “do not taunt Happy Fun Ball” disclaimer, it’s in small print. The effort is to close the sale, not to educate in order to let someone make an informed decision.

… Published studies showed very high levels of satisfaction from those who used it, with the exception of very specific complaints – such as a bad smell from the area of the penis while the device was being used.

Then it turned out that a number of other cases of tetanus has occurred. According to documents Circ MedTech submitted to the WHO in 2016, a total of six cases of tetanus were reported by PrePex patients in Rwanda and Uganda from 2014 through 2016 (including the three already mentioned above). The symptoms began to appear 10 to 13 days after the beginning of the use of the device. Four of these patients, ages 18 to 34, died.

That tetanus risk is significantly higher in Africa was ignored, which is essentially the approach with any confounding factor in the HIV epidemic, as well. “BUT CIRCUMCISION!” And here we are.

Of course, it’s critical to ask if the six patients in the excerpt were informed of this risk. Or that tetanus is mentioned at all in the public health push, since the article states it’s been reported from “surgical” circumcisions in Africa, too. Or that death was a risk, whether from PrePex os “surgical circumcision”, again, as the article reports happened from the push for male circumcision. But at least they won’t get HIV?

The company’s website is still available, despite the company ceasing operations. In a non-shocking discovery, I see that, like the New York Times in its initial advertisement-posted-as-news (see above), Circ MedTech linked to CIRCLIST as a “useful” source of information (along with Brian Morris’ nonsense). This link existed from at least September 6, 2014, according to Internet Archive. At the same time, CIRCLIST included a few fascinating pieces for consideration. These include information on FGC/M (NSFW), in which the distinction is “modifies the female genitalia in ways likely to be accepted by a neutral observer as [enhancing/reducing] the quality of a woman’s sexual experience”. Is there any concern¹ for consent?

CIRCLIST also contained a section on “Women’s Preferences and Experiences” of male circumcision, including a submission from Alexis (Canada) described as “a mother decides to re-circumcise her sons”. The story:

After reading about re-circumcision on the CIRCLIST website I decided to have my two sons re-circumcised. I was never happy with the loose skin that was left over by the doctor at birth. (The same Doctor did both boys). So I arranged it with a urologist and my sons, age 10 and 14 at the time, now have beautifully tight circumcisions. There is absolutely no movement of shaft skin towards the head of their penises, which I just adore and reckon that their future lovers and wives will adore it too and thank me for having it done. Now that the heads of their penises are fully exposed and permanently bared, I can personally say that the appearance is much sexier to look at and cleaner as well. I also encourage my boys to appreciate the look of their newly remodeled penises and to not be shy around girls because, when those girls get a look at their super tight circumcisions they will just go crazy for them.

Obviously there’s no way for the reader to know if Alexis is a real person or that her ode to pedophilia actually occurred. (It seems to have been disappeared from CIRCLIST sometime in 2015.) But publishing it was informative as to both the motive of CIRCLIST and its editors’ standard for what’s reasonable to do to children. And Circ MedTech linked the site as “useful”.

¹ That’s rhetorical, as consent is rarely considered within the pages of CIRCLIST.

“Being Targeted”, Predictably

The latest strategy to circumcise children is underway:

Over 900 boys and men in Mombasa County are being targeted for circumcision in a new drive by the government to reduce new HIV infections caused through the exercise.

The National Aids and STI Control Programme (NASCOP) said on Friday that it is targeting men aged between 10 and 50 years to undergo the cut under Voluntary Medical Male Circumcision (VMMC).

The first paragraph mentions boys. The second paragraph discusses 10-year-old men, because fewer would participate in the lie of “voluntary”. It’s always this way in advocating for circumcision, with the meaning of words being malleable to the goal. (e.g. “Medical” rather than “medicalized”) When public health officials advocate for voluntary, adult male circumcision, they never mean “voluntary” or “adult”.

The Lie Feeds Itself – PrePex Is Predictably More Unethical on Circumcision

Over the course of five years, it’s been clear where PrePex would go. Circ MedTech made it clear earlier this year that it would not be satisfied with a device aimed at voluntary, adult male circumcision. It only cares about two of those four words. Its adherence to the use of PrePex in voluntary, adult circumcision was always a delay in technology, not a wall of ethics. Now, it shares predictable evidence of its lack of ethics in developing and promoting PrePex. From its FAQ, Is PrePex available for adolescent boys?

The manufacturers of PrePex are committed to assisting males of all ages with appropriate male circumcision technology. Non-surgical circumcision using PrePex is now available for males ages 13 years and above. Devices for Infants & Children (0 days to 13 years) based on the existing PrePex technology are underway.

The only appropriate male circumcision technology appropriate for a normal, healthy male under 18 who does not – or cannot – consent is the technology that remains in the package, unused. Instead, Circ MedTech wants to assist¹ males of all ages, whether or not they want – or will ever want – to be assisted. It does not care about voluntary or adult.

Note that, despite being dated December 3, 2014, that link did not include the italicized language on April 22, 2016. It stated:

The manufacturers of PrePex are committed to assisting males of all ages with appropriate male circumcision technology. Non-surgical circumcision using PrePex is not yet available for youths under the age of 18, although it is being developed and tested.

An ethical organization would not mislead in this manner. I will not pretend to be surprised, however small the offense.

Circ MedTech’s absurdity with language continues in Who is eligible for circumcision with PrePex?:

PrePex has been proven safe and effective for adult and adolescent men over the age of 13. In studies to date, approximately 90% of men who volunteered were eligible to undergo the procedure. Men interested in medical male circumcision should consult with a trained healthcare provider to determine whether PrePex is right for them.

Every time I think circumcision advocacy can no longer shock me, something ridiculous like “adolescent men” appears. Dare I predict the eventual use of “infant men”? Surely that’s too absurd?

I have another ethics question. Did all of the “adolescent men” volunteer, or were they volunteered by their parents. And it’s disgusting² that the prospective patients in “Is PrePex available for adolescent boys” became “adolescent men” when discussing the actual circumcision of those healthy-and-unable-to-consent individuals.

On April 21st, that link stated:

PrePex has been proven safe and effective for adult men over the age of 18. In studies to date, approximately 90% of men who volunteered were eligible to undergo the procedure. Men interested in medical male circumcision should consult with a trained healthcare provider to determine whether PrePex is right for them.
Non-surgical circumcision is not yet recommended for youth under the age of 18 outside the clinical evaluation framework. Several African countries are currently investigating the safety and efficacy of the PrePex procedure for adolescent men, and study results should be available in early 2014.

“Adolescent men” was already there, but within one two-sentence paragraph, Under-18s transitioned from youths to adolescent men. That’s at least impressive in its shamelessness, I suppose.

As always, when public health officials speak of voluntary, adult male circumcision, they never mean voluntary or adult.

¹ The violation of rights seems to require euphemisms.

² I rewrote the euphemism I initially used. I prefer to speak truthfully.

Joint Government Effort to Eradicate Consent

As always:

The Ministry Of Information and Communication Technology in partnership with the Ministry of Health and the centre for Disease Control in America are collaborating on a National Strategic framework known as the Voluntary Medical Male programme which is a joint government effort to eradicate the long struggle of HIV/AIDS infections.

HIV/AIDS has always been the countries top priority with the health ministry being pressured to reach their ambitious 2030 vision to bring HIV/AIDS infections to zero in the country.”The Centre for Disease Control and the Ministry of health have had three randomised controlled trial runs of the voluntary medical male circumcision programme prior to it’s launch in 2009. With the success of the programme around 20,000 sexual active males have been circumcised to date thus raising 80% awareness to men to encourage more males in considering medical circumcision,”said programme specialist Mr Dan Rutz of CDC.

Somehow success is measure in “males circumcised” without giving any statistics on HIV rates¹. So it’s easy to predict what “encouraging more males to consider ‘medical’² circumcision” means:

“Medical male circumcision has been found to be cost effective, as well as all procedures are free at clinics it has been known that healthy employers increases work productivity within any work environment which leads to a steady healthy work environment that enables the economy to grow,” added Rutz.All males that have not been circumcised are encouraged to do so as procedures can be performed at all local regional clinics in the country as government want to achieve it’s target to circumcise 330,000 men between 15 to 49 years by the end of 2016.The Ministry would also like to implement a national policy programme known as an Early Infant Circumcision strategy in the near future that will enable newly born babies to be circumcised.

“Enable”. Newborn males won’t get to consider or volunteer. They will be considered and volunteered, their needs, preferences, and preventative options deemed irrelevant. They are only pieces by which public health officials measure their own professional success.

As always, when public health officials discuss voluntary or adult circumcision, they never mean voluntary or adult.

¹ A drop in HIV infections would be welcome. It cannot justify violating ethical obligations to protect the rights of non-consenting individuals.

² Circumcision in this context is medicalized, not medical. Merely performing non-therapeutic genital cutting in a sterile operating environment does not make it necessary. This is also not a defensible term to justify performing non-therapeutic genital cutting on a person who does not offer explicit consent.

Put Health Before Politics

I’ve never had much respect for public health officials when it comes to infant circumcision. When they say adult or voluntary, they never mean it. It’s also seemed clear for a long while that they’re not much interested in health, either. The latest example is New York City Mayor Bill De Blasio’s approach to protecting infants from herpes transmitted during metzitzah b’peh. I’m ignoring for now the horrible optics of the new makeup of the New York City Board of Health. The actual proposal allegedly aimed at protecting the health of infant males:

The mayor’s proposal, which requires approval by the board and will be presented on Wednesday, is … would waive a requirement that parents sign a consent form before the ritual, which involves sucking blood from the incision on a baby’s penis.

Instead, the mayor’s plan would create an alternative system that would test a circumciser, or mohel, for herpes, although only after a baby is found to be infected. If the circumciser tests positive, penalties would be pursued if DNA tests can prove that the mohel and the baby were infected with the same strain.

We know infection happens with metzitzah b’peh. We know that herpes can have devastating effects on infants. That alone should be enough to demand a proactive rather than reactive approach to protecting the health of infants. The case for a potentially effective plan, not this proposal, is impossible to ignore when also remembering that infants have rights that the government and Board of Health are no less obligated to protect.

The consent rule, introduced under Mayor Bloomberg, was assailed by Orthodox leaders as an infringement of their religious rights. Mr. de Blasio pledged to rescind the rule, and his aides later said the consent forms had been difficult to enforce, saying that herpes infections linked to the practice actually rose in 2014.

“This approach hasn’t been working in the past, and we need a new approach to truly reduce the health risk for infants,” Mr. de Blasio’s press secretary, Karen Hinton, said in a statement on Tuesday. Ms. Hinton added that the mayor had an “obligation to ensure that the Board of Health is fully staffed with highly qualified health experts.”

Protecting the bodily integrity rights of all infants is a new approach to reduce the health risk for infants. We haven’t tried that yet. And trying that is the ethical approach.

I don’t pretend protecting the rights of all infants, the correct approach, will be easy. Even with the “consent” document Mayor Bloomberg implemented, infections increased. Protecting the rights of infants in law and in reality are separate issues. The former would not guarantee the latter. But public health officials, ostensibly entrusted to (ethically) protect the health of all members of society, must aim for effectiveness, not politics.

The stink of uneaten side orders

Continuing on the implication from the government possibly reversing itself on cholesterol recommendations, Charles Lane ponders what the reversal means for public health and policy in, Science, with a side order of humility. Since this is not a diet blog, this is what matters here:

There’s a lesson here for all of us, especially those who urge that this or that public policy be dictated by “the science.”
…

We’re doomed to rely on science; imperfect as it is, it beats the alternatives. The trick is for scientists to produce their work with appropriate humility, and for citizens to consume it with appropriate skepticism. …

Precisely because it is, or aspires to be, value-free, science is better at describing social problems than solving them. Policymaking is all about value judgments and trade-offs. Science can prove that man-made climate change, for example, is real; the “right” way to address it is a matter of morality and politics.

In the past Mr. Lane very much cared about “the science” of circumcision in the way he rebukes above. Commenting on reactions to the Cologne court decision in 2012, before German legislators (i.e. policymakers) passed a law to override the court, Lane wrote (several links omitted):

I suppose I would agree with the court, and Andrew [Sullivan], if there was definitive proof that male circumcision, even performed under medically appropriate conditions (as the vast, vast majority are), constitutes “barbaric” “mutilation” of the genitals. Thorough as always, Andrew musters a video of some uncircumcised Canadian guy talking about masturbation and a blog post by an Oxford philosophy prof to prove that a) foreskin serves a vital sexual function and b) studies showing circumcision prevents HIV transmission are flawed.

The truth is that male circumcision does no permanent harm and might be slightly beneficial. There are risks to the procedure, but they are generally exceedingly minor. Both the American Academy of Pediatrics and the American Urological Association take the position that neonatal circumcision is a choice that may be safely left to the informed discretion of parents. Among other insults, the Cologne court impugns parents’ concern for the health of their own children.

On the sexual function point, the World Health Organization has declared that it “has not been systematically reviewed, and remains unclear due to substantial biases in many studies.” To those like Andrew’s Canadian dude who insist that missing foreskin would diminish sensation, I offer the circumcised Woody Allen’s famous assessment of his orgasms: “My worst one was right on the money.”

Anyway, injury to this bit of erogenous tissue would not be mutilation of the “genitals,” strictly speaking, since it plays no direct role in male reproduction.

Witness how Lane discarded the position that male circumcision constitutes mutilation. The claim comes from “some uncircumcised (sic) Canadian guy talking about masturbation and a blog post by an Oxford philosophy prof,” so we can dismiss it. That’s ad hominem, not refutation. Experience is anecdotal, but can be informative. And philosophers should obviously be involved. Non-therapeutic circumcision by proxy consent implicates ethics and rights, particularly – but not limited to – the rights of the child as expressed by the German court.

Rather than discussing the ways studies may be flawed to rebut them, Lane moved on to his opinion, omitting the fact that removing the foreskin itself constitutes harm. He quotes two professional organizations to support his position (while ignoring the flaws in the AAP’s position, for example). Enjoy what he wrote yesterday:

Doctors and researchers, authors of “medical miracles,” are more like a priesthood, or a cadre of sorcerers, than we generally admit. Their legitimacy is based on something real, and time-tested — the scientific method — but it also comes from the mystique of their diplomas and white coats.

He supported a policy statement based on science applied as value judgement and trade-off, with input on the value judgement and trade-off from everyone except the person upon whom it’s applied.

He moves on to the World Health Organization’s statement that sexual function “has not been systematically reviewed, and remains unclear due to substantial biases in many studies.” So we’re just supposed to accept that “male circumcision does no permanent harm”? Why? I don’t remember learning that the scientific method says we may assume whatever is necessary for our argument in the absence of reliable data, bolstered because someone told a joke once.

Lane showed his full (2012) commitment to SCIENCE! rather than science in the last quoted paragraph. If the foreskin is erogenous, why did he argue that removing it permanently does “no permanent harm”? More to the point, if someone sliced up my leg with a razor, leaving scars, would he say I’m not mutilated because I can still walk? His argument was nonsense, including the implication that the foreskin is not part of the genitals.

I wonder if Mr. Lane would reconsider his misguided 2012 analysis today with a side order of humility previously absent. He should.

**********

There are more problems with Lane’s 2012 essay than what I criticize here. He was wrong from start-to-finish in that essay.

Unsettling the settled

This has no direct connection to circumcision or genital integrity. But it has pertinent implications right now.

The nation’s top nutrition advisory panel has decided to drop its caution about eating cholesterol-laden food, a move that could undo almost 40 years of government warnings about its consumption.

The group’s finding that cholesterol in the diet need no longer be considered a “nutrient of concern” stands in contrast to the committee’s findings five years ago, the last time it convened. During those proceedings, as in previous years, the panel deemed the issue of “excess dietary cholesterol” a public health concern.

The new view on cholesterol in the diet does not reverse warnings about high levels of “bad” cholesterol in the blood, which have been linked to heart disease. Moreover, some experts warned that people with particular health problems, such as diabetes, should continue to avoid cholesterol-rich diets.

After decades of one recommendation, the U.S. government discovers that settled science isn’t quite as settled as it led citizens to believe. This lesson arrives in the lull between the comment period and issuance of the CDC’s circumcision recommendation. The ethics of genital integrity dictate against its proposal. Of course. But looking forward, how much of the “settled” science of circumcision rests on speculation and guesswork? What might change over the next few years and decades? What will the CDC (or AAP or WHO or…) say if, in 2035, something unsettles¹ the science so many (almost exclusively American) authorities eagerly endorse today? Will the boys born today accept an “Ooops” for what is being forced on (i.e. taken from) them today if something unsettles the science tomorrow?

¹ The ethics of non-therapeutic genital cutting without the individual’s consent “unsettles” it now by making the application of the science in that manner inherently wrong. The availability of more effective, less invasive preventions and treatments for maladies involving the foreskin already unsettles the science, as well.

President’s Endless Plan for Avoiding Rights

PEPFAR held an event today, described as:

Join global health experts in PEPFAR’s sixth VMMC Webinar to consider the pros and cons of offering early infant male circumcision (EIMC) as part of routine Maternal, Newborn and Child Health (MNCH) care.

The title of the event was, “Scaling Up Routine Early Infant Male Circumcision within Maternal, Newborn and Child Health”. I wonder what the outcome of considering the pros and cons will be.

It’s also worth noting how circumcising infants has been separated as EIMC from “voluntary” male “medical” circumcision (VMMC). Is it progress if they’ve stopped pretending that infant circumcision is voluntary? Not really, I think, since no one involved cared anyway and dropping it means they’re comfortable with making it clear they don’t care.

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

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?

Another Reminder

When public health officials advocate for voluntary adult male circumcision, they never mean voluntary or adult. From Zimbabwe:

The ministry was working together with the Population Services International (PSI) on the programme.

PSI director for voluntary medical male circumcision Ngonidzashe Madidi said for the purposes of sustainability, they were studying the early infant male circumcision (EIMC) to ensure protective effect of male circumcision is sustained.

Madidi said they wanted EIMC to run parallel with the adult Voluntary Medical Male Circumcision (VMMC) programme.

“Currently, EIMC is in a study phase and we are happy to say we managed to circumcise at least 560 babies successfully,” Madidi said.

Are the infants happy? Do they think it was successful?