Journalists Doing Brian Morris Undeserved Favors

It isn’t difficult to see how Brian Morris’ process works. He publishes a “new” paper making bold, biased, often-unsupported claims citing his prior work doing the same, and receives circulation for his ideas from unquestioning journalists acting as stenographers. His latest, with Stefan Bailis and Thomas Wiswell, is a good opportunity to assess the reporting within consideration of an excellent article by Ian Sample, “How to write a science news story based on a research paper“.

1. Find a good paper

That rules out anything written by Professor Morris, but I’ll grant that his focus on non-therapeutic infant male circumcision satisfies the criteria that the work be “controversial”.

2. Read it

You cannot cover a paper properly without reading it. The abstract [ed. note: Or the press release] will give the barest essentials. You need to read the introduction for context, the discussion and conclusions for take-home messages. Check the methods. Was the experiment well designed? Was it large enough to draw conclusions from? Find weaknesses and flaws. You will probably need help to work out how fatal they are. Spend time on the results. Have the authors omitted key data? Look at odds ratios, error bars, fitted curves and statistical significances. Are the results robust? Do they back up the scientists’ conclusions? …

Given that Morris’ latest paper is only 10 pages (pdf), including references, this shouldn’t be hard. Yet, I found no initial article covering it that suggested the reporter bothered to read beyond the press release, or perhaps the abstract. For example, both of these articles cite the “benefits exceed risks by at least 100 to 1” line as truth, despite there being no support within the paper for this preposterous claim. It’s merely a statement. Where is the support for this in the paper? The questions Mr. Sample suggest provide a path for investigating this paper further. There is a table of potential benefits cited for circumcision, but no data offering how these are weighted to produce an objective mathematical conclusion.

Within the key table listing claimed benefits, Table 4, Morris cites a study by Dr. Jonathan Wright while omitting the necessary qualification that the study found a correlation, not a causal link. As Dr. Wright stated, “‘These data suggest a biologically plausible mechanism through which circumcision may decrease the risk of prostate cancer,'” said study researcher Dr. Jonathan Wright, an assistant professor of urology at the University of Washington School of Medicine. He noted that the study was observational; it did not show a cause-and-effect link.” How much does this correlation contribute to the “100 to 1” number?

4. Get context

Science builds on science. Know the previous studies that matter so you can paint a fuller picture. …

Like Dr. Wright’s study, for example. Or the way Morris previously used a study by Dr. Kimberly Payne to support a claim that the “highest-quality studies suggest that medical male circumcision has no adverse effect on sexual function, sensitivity, sexual sensation, or satisfaction.” Yet, Dr. Payne’s study, which Morris (and Krieger) rated as the highest quality, resulted in Dr. Payne stating that “[i]t is possible that the uncircumcised penis is more sensitive due to the presence of additional sensory receptors on the prepuce and frenulum, but this cannot be compared with the absence of such structures in the circumcised penis.”

5. Interview the authors

Get them to explain their results and justify their conclusions. What do the results mean in plain English? What do they not mean? Ask your questions in simple language to get answers you can quote. Run phrases you might use past the authors, so they can warn you of howlers. Do not ask multi-part questions: you will not get full answers.

Perhaps Morris should justify making up rights when he says “[d]enial of infant male circumcision is denial of his rights to good health, something that all responsible parents should consider carefully”. Do parents who do not circumcise their healthy son violate his rights?

This is especially interesting in light of a comment in the press release. Professor Morris said (emphasis added):

“The new findings now show that infant circumcision should be regarded as equivalent to childhood vaccination and that as such it would be unethical not to routinely offer parents circumcision for their baby boy. Delay puts the child’s health at risk and will usually mean it will never happen.

If not circumcising an infant male “will usually mean it will never happen”, that demonstrates that circumcision will usually not be necessary. Is this one surgery, and the ethical implication, somehow different than withholding from a healthy child every other surgery that will usually never be required?

This also shows the sleight-of-hand in “half of uncircumcised males will require treatment for a medical condition associated with retention of the foreskin,” which is included in the paper (and on Morris’ site). Requiring treatment is not the same as requiring circumcision.

In footnote e of Table 4, Morris cites a figure for risks associated with neonatal circumcision where “data show that risk of an easily treatable condition is approximately 1 in 200 and of a serious complication is 1 in 5000”. So, a complication is not an argument against non-therapeutic infant male circumcision because it will probably be easily treatable. And treatable medical conditions associated with the foreskin will usually not require circumcision, as Professor Morris states, but somehow also justify non-therapeutic infant male circumcision. That’s “Heads I win/Tails you lose” nonsense. Professor Morris is engaging in propaganda.

When the New York Times quoted Morris about this paper, he said: “Just as there are opponents of vaccination, there are opponents of circumcision. But their arguments are emotional and unscientific, and should be disregarded.” That is demagoguery, and should reflect on Professor Morris’ reputation. The argument against non-therapeutic infant male circumcision is rooted in ethics, but it is also rooted in the science of normal human anatomy. The foreskin is healthy, just as every other body part usually is. And opponents of non-therapeutic child circumcision support condoms, soap, and antibiotics, for example, which are all scientific inventions and discoveries.

6. Get other scientists’ opinions

Such as Professor Kevin Pringle, of New Zealand, and Dr. Russell Saunders, pen name for a New England pediatrician. While I disagree with the latter’s conclusion on parental choice, for my purpose in this post, he wrote: “Having reviewed Dr. Morris’s study, I find his statements about the benefits of circumcision as a routine procedure overblown, and the comparison with vaccination baseless.”

7. Find the top line

How about this, from page 7 of the paper:

The timing of circumcision is crucial. Medical and practical considerations strongly favor the neonatal period (Table 4).16 Surgical risk is, thereby, minimized and the accumulated health benefits are maximized.14,16 …

As Morris’ statement about the likely lack of need demonstrates, circumcising in infancy is not usually crucial for the male’s health to the point of circumcision becoming necessary. There isn’t a justification for non-therapeutic infant circumcision. It can wait until the male can choose – or reject – non-therapeutic circumcision for himself.

8. Remember whom you are writing for

This is where Morris gets what he needs most. The headlines encourage readers who only skim headlines to believe that Morris has proven that the potential benefits exceed the risks 100 to 1, that circumcision is similar to a vaccine, and that there is some case for mandatory circumcision of infants. It’s all absurd and does a significant disservice to readers and truth.

9. Be right

Ahem.

Mark Joseph Stern Is Mistaken On Circumcision

It takes a special commitment to ignorance to cherry-pick evidence to prove that opponents cherry-pick evidence. Mark Joseph Stern possesses that special commitment.

There are facts about circumcision—but you won’t find them easily on the Internet. Parents looking for straightforward evidence about benefits and risks are less likely to stumble across the Centers for Disease Control and Prevention than Intact America, which confronts viewers with a screaming, bloodied infant and demands that hospitals “stop experimenting on baby boys.” Just a quick Google search away lies the Circumcision Complex, a website that speculates that circumcision leads to Oedipus and castration complexes, to say nothing of the practice’s alleged brutal physiological harms. If you do locate the rare rational and informed circumcision article, you’ll be assaulted by a vitriolic mob of commenters accusing the author of encouraging “genital mutilation.”

One paragraph in, and there’s so much to unpack. First, the obvious point is that Mr. Stern is another in a long line of lazy writers who thinks that the ability to type a word into Google proves much of anything for a story. If it’s just “a quick Google search away”, in a paragraph filled with links, it’s reasonable to expect an author to include the search he used to get to the evidence of alleged malfeasance. When I use Google to search circumcision, I get Wikiepdia, news articles, KidsHealth.org, the Mayo Clinic, the government’s Medline Plus, Intact America, Jewish Virtual Library, NOCIRC, and so on. I’ll point out that only the results for Intact America and NOCIRC are to something decidedly against non-therapeutic child circumcision, but so what? It’s a search algorithm. That’s easily gamed. It doesn’t prove Mr. Stern’s silly angle.

That “rare rational and informed circumcision article” is another in Hanna Rosin’s string of awful circumcision defenses.

As for the vitriol, this is the internet. Never read the comments. That doesn’t excuse the comments. They’re often offensive and uninformed and the people who engage in that behavior are wrong, even if they’re ostensibly on my side. But you’ll find them on both sides. It doesn’t prove anything on the argument. Using it as evidence against the argument is ad hominem.

So. There are facts about circumcision. Circumcision is the “surgical removal of the foreskin of males”. The foreskin is the “loose fold of skin that covers the glans of the penis”. Those are facts. But he’s implying the context of non-therapeutic male child circumcision. What should parents want?

Parents shouldn’t want anything, of course, because this is not their decision. Just like we don’t allow them to cut off any other normal body parts of their children, they do not possess a right to circumcise their sons for any reason other than immediate medical need that can’t be adequately resolved with less-invasive methods. Proxy consent is not sufficient for non-theratpeutic circumcision. But because our society doesn’t yet grasp the full implication of an equal right to bodily integrity, parents want information. Fortunately, there is scientific evidence against non-therapeutic circumcision!

The normal, healthy foreskin is normal and healthy. If parents leave it alone, as they should, statistics demonstrate that their son(s) will almost never need any intervention for his foreskin, and much less a medically-necessary circumcision.

Of every 1,000 boys who are circumcised:

  • 20 to 30 will have a surgical complication, such as too much bleeding or infection in the area.
  • 2 to 3 will have a more serious complication that needs more treatment. Examples include having too much skin removed or more serious bleeding.
  • 2 will be admitted to hospital for a urinary tract infection (UTI) before they are one year old.
  • About 10 babies may need to have the circumcision done again because of a poor result.

In rare cases, pain relief methods and medicines can cause side effects and complications. You should talk to your baby’s doctor about the possible risks.

Of every 1,000 boys who *are not* circumcised:

  • 7 will be admitted to hospital for a UTI before they are one year old.
  • 10 will have a circumcision later in life for medical reasons, such as a condition called phimosis. Phimosis is when the opening of the foreskin is scarred and narrow because of infections in the area that keep coming back. Older children who are circumcised may need a general anesthetic, and may have more complications than newborns.

Those numbers, from the Canadian Pediatric Society, are hardly compelling in favor of circumcising healthy children. Non-therapeutic circumcision prevents 5 boys (0.5%) from being admitted to a hospital with a UTI in the first year of life. Yet, between 20 and 30 (2-3%) boys will suffer a surgical complication, and another 2 to 3 (0.2-0.3%) will suffer a more serious complication.

The really curious statistic is the last in each group. About 10 (~1%) babies may need to have the circumcision done again due to a poor result. If normal, healthy boys are left with their normal, healthy foreskin, 10 (1%) of them will need a medically-necessary circumcision later in life. Those numbers look curiously similar.

So, to recap the facts in this context, circumcision is the permanent removal of a normal, healthy foreskin from a boy who can’t offer his consent to eliminate the 1% lifetime risk that he’ll need a circumcision.

There are other potential benefits, which Mr. Stern links in great detail. I have no problem including them, regardless of how weak or stupid I think they may be. That still isn’t enough to permit non-therapeutic child circumcision. The inputs into the decision are facts, but their value is not. Each person is an individual with his own preferences that his parents can’t know. What Mr. Stern values is not automatically what I value. Or to make the more appropriate connection, what parents value is not automatically what their son will value. That is why proxy consent requires a stricter standard than consent. A surgical decision that permanently alters a healthy child’s body can’t be permitted within proxy consent.

Mr. Stern writes this curious statement among many curious statements:

… Yet in the past two decades, a fringe group of self-proclaimed “intactivists” has hijacked the conversation, dismissing science, slamming reason, and tossing splenetic accusations at anyone who dares question their conspiracy theory. …

What a specific subset of people do is hardly the entirety of the argument or proof in favor of his position. Again, this is just silly, indefensible ad hominem. But what he says is also untrue. Dismissing science? Not here. I’ll accept any claimed benefit. The argument against forcing circumcision on a child is still as powerfully conclusive. Slamming reason? Stating that normal, healthy children should not undergo surgery is the position using reason. Conspiracy theory? Nope. Parents who circumcise, and people who support that option, are generally well-intentioned. I can show examples where that isn’t true, but I’m aware that such evidence is isolated. It’s surely true that some doctors circumcise for the money. I assume most circumcise because they believe it’s acceptable or believe parents should choose, even if the doctor wouldn’t. It’s important to understand how we got here, but I don’t much care about placing blame for that. I care about moving forward. There are any number of like-minded individuals Mr. Stern could find and talk to rather than write the wrong things he wrote.

… For doctors, circumcision remains a complex, delicate issue; for researchers, it’s an effective tool in the fight for global public health. But to intactivists, none of that matters. …

All of that matters. No one I know believes that adult (or older teen) males shouldn’t be able to volunteer for non-therapeutic circumcision.

Mr. Stern’s tactic here is what he’s complaining about. It’s similar to when Dr. Amy Tuteur goes on a tedious rant about “foreskin fetishists”. Smear your opponents because they smear you. “They”, of course. Internet comments are a part of humanity, not representative of it.

… The first rule of anti-circumcision activism, for instance, is to never, ever say circumcision: The movement prefers propaganda-style terms like male genital cutting and genital mutilation, the latter meant to invoke the odious practice of female genital mutilation. (Intactivists like to claim the two are equivalent, an utter falsity that is demeaning to victims of FGM.)

I’ve written circumcision a whole bunch above. But circumcision is genital cutting, because facts. The comparison is in the principle of those facts. Non-therapeutic genital cutting on a non-consenting individual is unethical. It’s also genital mutilation if we are to accept the WHO definition of female genital mutilation:

Female genital mutilation (FGM) comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.

… It is nearly always carried out on minors and is a violation of the rights of children. The practice also violates a person’s rights to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death.

The issue is human rights, not a specific subset of human rights from which male minors are somehow exempt.

Anti-circumcision activists then deploy a two-pronged attack on some of humanity’s most persistent weaknesses: sexual insecurity and resentment of one’s parents. Your parents, you are told by the intactivists, mutilated you when you were a defenseless child, violating your human rights and your bodily integrity. Without your consent, they destroyed the most vital component of your penis, seriously reducing your sexual pleasure and permanently hobbling you with a maimed member. Anti-circumcision activists craft an almost cultic devotion to the mythical powers of the foreskin, claiming it is responsible for the majority of pleasure derived from any sexual encounter. Your foreskin, intactivists suggest, could have provided you with a life of satisfaction and joy. Without it, you are consigned to a pleasureless, colorless, possibly sexless existence.

Some take that approach. I only speak for myself on being unhappy with circumcision. I’ll quote myself on his generalization:

… The problem is not that circumcision is bad, per se. Healthy men who choose to have themselves circumcised are correct for their bodies. Men circumcised as infants who are happy (or indifferent) about being circumcised are also correct for their bodies. …

But if you only dive into comments sections, it’s easy to believe that’s the only opinion. It’s not excusable to believe that, but it’s easy.

Intactivists gain validity and a measure of mainstream acceptance through their sheer tenacity. Their most successful strategy is pure ubiquity, causing a casual observer to assume their strange fixations are widely accepted. Just check the comment section of any article pertaining to circumcision. …

Ahem.

Take, for example, the key rallying cry of intactivists: That circumcision seriously reduces penis sensitivity and thus sexual pleasure. …

My “key rallying cry” is that circumcision is medically unnecessary and violates the child’s basic rights to bodily integrity and autonomy. That holds up even if the rest of his paragraph’s citations hold up. Sexual satisfaction is a subjective evaluation to each individual. The ability to orgasm is not the full universe of sexual satisfaction. And any change to form changes function. The individual may view that change as good. He may view it as bad. Parents can’t know. That’s the ethical flaw in circumcising healthy minors.

Study after …

Surely Mr. Stern read through the studies to understand exactly what they say. I have my doubts. I read it. That study is problematic when viewed as conclusively as Mr. Stern cites it. It requires nuance the study’s author provided. Does an appeal to authority sweep away any concerns about limitations?

study after …

Adult male circumcision does not adversely affect…” Is that proof that circumcision of male minors doesn’t affect sexual satisfaction, with the glaring caveat against surgery that such a male can’t know?

It’s also worth noting that Mr. Stern linked that same study again later in the paragraph. He also linked another study in consecutive sentences. And a third. That’s deceptive and improperly gives an impression about “an entire field of resarch”, no?

… ([No adverse effect] fits with what my colleague Emily Bazelon found when she asked readers for their circumcision stories a few years ago.) …

Ms. Bazelon’s premise and finding were ridiculous.

So much for circumcision’s supposedly crippling effect on sexual pleasure. But what about its effect on health? Intactivists like to call circumcision “medically unnecessary.” In reality, however, circumcision is an extremely effective preventive measure against global disease. …

The potential benefits don’t render non-therapeutic circumcision “medically necessary”. Earlier he complained about propaganda-style terms. Pretending that “medically unnecessary” doesn’t have an accepted, factual meaning is propaganda-style question begging.

… Circumcision lowers the risk of HIV acquisition in heterosexual men by about 60 to 70 percent. … [ed. note: (Later in this paragraph, he uses the WHO link again.]

The “60” link states “male circumcision should be considered an efficacious intervention for HIV prevention in countries and regions with heterosexual epidemics, high HIV and low male circumcision prevalence.” Not one of those three criteria matches a Western nation. Those studies also involved adult volunteers, not unconsenting minors.

As both a personal and public health matter, circumcision is clearly in men’s best interest. …

Ethically, as a personal health matter, each healthy individual should decide for himself what body alterations are in his best interest based on his own preferences.

… Anyway, to intactivists, mutilation is mutilation; what does it matter if it’s for the greater good?

“The greater good” doesn’t matter because individuals are humans with rights, not statistics to be treated without regard for what they need or want. Life is full of risks. Because we seemingly can mitigate that does not mean we may or should.

Dr. Lindsey Doe on Dealing with Sexual Injustices, Including Male Circumcision

Dr. Lindsey Doe, a clinical sexologist, hosts sexplanations on YouTube. It’s an excellent show that educates viewers on human sexuality. In the latest episode, “How to Deal with Sexual Injustices”, she talks about injustice with a focus on male circumcision. She is spot-on in her analysis and how to approach this injustice on a personal level. Please watch. (It’s obviously NSFW based on strong language and topics.)

The circle she created about circumcision is an excellent starting point. (Here’s a screencap of that circle.)

Know the Facts That Discredit Infant Circumcision

In a typical example of the “Facts About Circumcision” genre of public health journalism, this version from Zimbabwe demonstrates the usual public health misunderstanding of consent.

Reports that the Health ministry would make neonatal circumcision mandatory has also raised serious concerns.

But National Male Circumcision Coordinator in the Ministry of Health and Child Welfare, Sinokuthemba Xaba said male circumcision in Zimbabwe remained a voluntary procedure for adult males, neonates and infants.

“Those who are below 18 years have to have a consent form that is signed by a parent or legal guardian to allow them to go through with the procedure,” said Xaba. “In this regard, the programme remains voluntary and when the Health ministry rolls out Early Infant Male Circumcision, it will still be voluntary, where the parent volunteers and signs the consent form to allow the male child to be circumcised.”

This interpretation butchers all meaning from the word voluntary. Circumcision forced onto a healthy child who can’t provide his consent to permanent bodily alteration is not “voluntary”. Ignoring the healthy patient shows a belief that consent is a form to be signed rather than a concept for respecting basic human rights.

Xaba said there was a study that was being done to ascertain the safety of infant circumcision.

“It is focusing on the safety, feasibility and acceptability of early infant male circumcision,” said Xaba.

Sure it will be studied, but without studying the acceptability of early infant male circumcision to the male being circumcised in early infancy. It rarely means anything to public health officials that the number of males unhappy being circumcised as infants is non-zero. They do not concern themselves with individual rights. Their population is one, “the public”. As such, they never mean voluntary when they use the word voluntary.

For example:

“The programme will only be availed and rolled out, based on the findings of this study. Therefore, when it is available, it will be a safe procedure for the infants.”

It will be available. It will be inflicted on non-consenting infants. The outcome of the study – of acceptability – is known before it’s completed.

The article contains some discussion of legitimate individual consent and rights from citizens. There are rational voices for individual rights, but one pro-infant circumcision comment reveals a truth I’ve discussed before that is too often overlooked (or denied, contrary to evidence):

Some women said child circumcision was an opportunity to take control of their children’s destiny and shape it into a brighter future.

“It is all for their benefit, so I do not see where the issue of rights is coming from,” said Memory Mhishi, a shop assistant in a clothing boutique along First street.

This¹ is the belief that intention matters more than action. The attitude is that as long as parents intend to do good, we must not question the means within currently accepted standards. We must adhere to that even in areas where infant circumcision is now being introduced, as opposed to it being a long-standing tradition. But that demand is preposterous. Forced genital cutting for whatever non-therapeutic potential benefit parents seek is inherently a form of control. It’s a statement that the child should want this and, because he might reject it, his choice may be taken away from him “for his benefit”. That is indefensible if human rights matter. Human rights matter.

¹ Please please please do not focus on “Some women…” in that quote. If you obsess on that, you’re injecting your own agenda and problems into the debate that should be focused on protecting the bodies and rights of children. Men/fathers say the same thing “some women” told the author.

The AAP Discounts Its Patients’ Right to Physical Integrity

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.”

Ghana Encourages Unethical Infant Circumcision

As always, when public health officials endorse voluntary, adult male circumcision to reduce the risk of (female-to-male) HIV transmission, they never mean voluntary or adult. Today, Ghana:

Dr Gloria Asare, a Public Health Consultant, has said male circumcision was one key area of HIV and AIDS prevention and appealed to families to circumcise their male children.

Someday we won’t let good intentions and fear blind us to the fatal ethical flaw within non-therapeutic infant circumcision. We will endorse and require consent from the patient rather than proxy consent for the patient.

Dr Limakatso Lebina’s Ridiculous Circumcision Euphemism

Anyone familiar with the way voluntary, adult male circumcision is being promoted as a way to reduce the risk of female-to-male HIV transmission in high-risk populations already knows how it’s promoted. The brochure excludes context-specific qualifiers. That mouthful in the first sentence is always shortened to “circumcision reduces the risk of HIV”, even though that broad statement isn’t supported by the studies. In addition, voluntary, adult male circumcision loses words over time. Adult was the first word to go. Voluntary is still used, but that word doesn’t mean what it’s used to represent. Consent must only come from the patient when the circumcision is non-therapeutic. Absent that consent, the surgery shouldn’t be imposed on a healthy minor. In a discrediting move, no one adheres to that. It took six days from the 2006 release of the major HIV study on voluntary, adult circumcision in Africa for the U.N. to propose targeting infants first among all males in HIV-ravaged parts of Africa. Perpetuating circumcision via physical indoctrination is the new standard. Voluntary disappeared a long time ago as anything more than a marketing word.

I do not wish to suggest I think this is a conspiracy. Public health officials believe they are acting nobly. A well-meaning focus on one’s own preferences explains this at least as well. We must do something to reduce HIV. Circumcision is something. Therefore, we should circumcise. That’s bad logic, and relies too heavily on the nonsensical idea that someone happy with being circumcised proves everyone will be happy being circumcised. It treats the individual as a tool to achieve some public goal. That’s mistaken but it seems rooted in good intentions.

Now, knowing all of this, I’m difficult to surprise with how public health officials promote circumcision. I expect dumb, offensive strategies. I still can’t believe this from the opening of a new circumcision clinic at Tshepong Hospital in Klerksdorp, South Africa:

The clinic is called Gola Monna, or “Grow up Man” in Setswana. Its founder, Dr Limakatso Lebina, said: “This clinic will circumcise men and will ensure that they have lifelong partial protection against HIV.

“The removal of the foreskin clearly can’t stop all HIV infections but it certainly prevents most. [ed. note: dangerous misinformation] We tell all the men that we circumcise that they must continue to condomise,” she said.

Asked why women should be included, Dr Lebina explained: “Women should be involved in decisions about getting a safe circumcision. As mothers of boys and partners of men, they must ensure that the males in their lives are protected from HIV”

A quick pause to note how easily both adult and voluntary are missing as concepts in Dr. Lebina’s approach. This is more curious because MEC Dr. Magome Masike said that “communities must encourage men aged from 15 to 45 to come to this new clinic for circumcision.” A newborn male is not a man.

This, though, is absurd and offensive:

She added: “There is data to show women prefer circumcised men.[¹] So take a Valentine’s day decision to get a love cut and come in for male circumcision at the clinic.”

Rather than “voluntary” male circumcision, we have a “love cut”. This is no different than asking opponents “why do you want people to get HIV?,” as if one can’t be opposed to both non-voluntary forced circumcision and the transmission of HIV. Here, Dr. Lebina implies that an intact man who won’t have himself circumcised doesn’t love his partner as much as someone who would have himself circumcised. It’s preposterous. It also encourages parents to circumcise their sons because they love them. That’s twisted. Circumcision is not a gift.

Public policy needs to return to voluntary, adult male circumcision and mean it. Euphemisms like this, however well-intentioned, are Orwellian distortions that hide the ethical issues from those promoting and from those deciding on circumcision.

¹ The standard “women prefer circumcised men” is as expected here as it is irrelevant. Women (and men) are entitled to prefer whatever they want from a partner. They are not entitled to have it. What a partner prefers does not require a person to agree to have it done. Preference does not excuse imposing it on an individual in response to or as speculation about what a current or future partner prefers about his genitals.

International Day of Zero Tolerance to FGM, 2013

Today is International Day of Zero Tolerance to Female Genital Mutilation. The WHO statement on this is lacking, which I don’t find surprising. (emphasis added)

The International Day of Zero Tolerance to Female Genital Mutilation is observed each year to raise awareness about this practice. Female genital mutilation of any type has been recognized as a harmful practice and violation of the human rights of girls and women. WHO is committed to the elimination of female genital mutilation within a generation and is focusing on advocacy, research and guidance for health professionals and health systems.

Female genital mutilation (FGM) refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons. Female genital mutilation has no known health benefits. On the contrary, it is associated with a series of short and long-term risks to both physical, mental and sexual health and well-being.

FGM is affecting about 140 million girls and women, and more than 3 million girls are at risk every year. A special focus for WHO this year, is the troubling trend of health-care providers increasingly being the ones performing female genital mutilation, and thereby contributing to legitimize and maintain the practice.

Today, I’m not going to discuss the comparison to male circumcision beyond the one inherent in this sentence. I am going to use WHO’s approach to male circumcision to compare why its last sentence shouldn’t be a surprise.

Stating that FGM has no known health benefits works from the premise that the possibility of benefits could justify FGM. No benefit could justify forced FGC (i.e. mutilation). The human rights principle is superior. WHO should state that as its foundation, and be consistent and repetitive. In reminding readers about this lack of benefits, WHO almost apologizes for being against FGM. The absence of benefits is not why this shouldn’t be done.

Think back to when the AAP issued a revised policy statement on FGC, later retracted. As I wrote here and here, I didn’t/don’t think it said what people read into it. But the reaction was universal and swift. On the idea that permitting limited forms of genital cutting could prevent greater harm to females, activists stood on the absolute principle. Whether or not this makes sense is a worthwhile discussion. (My posts linked above set out my thoughts on the issue. The principle still matters more.) Regardless, that incident demonstrates that activists would never excuse FGC/M if benefits were proposed or found. Can anyone imagine a scenario where any scientific committee allowed research into possible benefits? For those inclined to accept possible benefits as a justification, everyone else must discourage this thinking. Lazy statements that lack the courage to defends what is morally and ethically correct fail that goal.

WHO’s approach, which informs its stance on male circumcision, enables the predictable problems described in the last sentence. Because the organization refuses to stand for principle where courage is necessary, it creates the conflict of legitimizing genital cutting through “medical” male circumcision programs. I know of no populations that cut females that don’t also cut males. So, WHO drives campaigns to legitimize genital cutting while driving campaigns to delegitimize genital cutting. The flaw is obvious. The principle and consistency matter.

Zimbabwe Commits to Unethical Infant Circumcision

In July I wrote about Zimbabwe’s plan to focus its “voluntary, adult” circumcision efforts on infants. This wasn’t a surprise because the truth always remains. When public health officials say voluntary or adult, they never mean voluntary or adult. And, as I wrote at the time in response to the claim that their “sole aim is to try and reduce new HIV infections”:

No, the sole aim is to implement circumcision. They believe their intentions are noble, a fact I do not doubt. But if their sole aim is to try to reduce new infections, they’d focus limited medical resources on those currently at risk of sexual transmission. They’re not, unless we stupidly assume all males aged 15 to 49 in Zimbabwe have been circumcised. Instead, they’re shifting to males who can’t consent. They still have 500,000 males to circumcise before 2015 to reach their target. The target is what matters, not the individuals being targeted.

There’s further evidence on both the low number of volunteers and the predictable efforts to “volunteer” infants. On the former (emphasis added):

Government intends to circumcise one million men between 2013 and 2015. The turnout has been very low in the previous years with only 85 000 circumcised since the inception of the programme. Chances of a man acquiring HIV from an infected partner if circumcised are less than 60 percent.

Instead of the 500,000 men who need to be circumcised, as reported in July, Zimbabwe is 915,000 men short of its goal. Or they intend to circumcise one million newborn “men”. Either way, it would be more prudent to ask why men (i.e. adult males) aren’t volunteering as expected than to violate healthy infants by forcing circumcision on them.

Also, notice the last sentence. In the best interpretation, it’s poor English. In the worst, it’s dangerously wrong. Regardless of the interpretation, men aren’t volunteering. Why? Instead of finding out, or publicly explaining why, public health officials push to impose non-therapeutic circumcision on children.

CHILDREN will soon be circumcised at birth under a national programme to achieve maximum results of the medical procedure, senior health officials have said. Aids and TB Unit director in the Ministry of Health and Child Welfare Dr Owen Mugurungi said Government was planning to start neonatal circumcision as soon as possible.

“We hope between 2013 and 2014 we would start neonatal circumcisions at a national scale,” he said. “It is actually more sustainable than adult circumcisions.”

Of course it’s more sustainable. Infants can’t refuse or fight back when they’re being violated. When public health officials say voluntary or adult, they never mean voluntary or adult. It’s easier.

[Dr Mugurungi] said for every 200 000 babies circumcised, about 1 500 new infections are averted.

Have they discussed the declining return, if their projections prove correct? (There is evidence to the contrary, as circumcised men in Zimbabwe may have a higher rate of HIV infection than intact men.) For every 1,500 fewer infections in their projections, the population-wide transmission rate decreases. Thus, the number of circumcisions needed to prevent each new infection increases. At what point in their flawed lack of ethics does the ethical question finally appear? When does the cost to individuals become too much to impose on them without their consent, allowing Zimbabwe to return to voluntary circumcision?

The answer, of course, is they haven’t and aren’t interested. The willingness to force circumcision on healthy infants is self-fulfilling. Ingrain it in the culture, and suddenly the rational respect for the current health and rights of infant males somehow appears absurd. The United States is evidence of this.

Joya Banerjee Misunderstands Opposition to Circumcision

Amazon.com reviews of Tinderbox: How the West Sparked the AIDS Epidemic and How the World Can Finally Overcome It, by Craig Timberg and Daniel Halperin, PhD, are the subject of a flawed essay by Joya Banerjee, titled “How an anti-circumcision fringe group waged an ideological attack against AIDS scholarship”. I doubt Ms. Banerjee wrote the headline, although it doesn’t much matter because she ues the same silly accusation in her article. After an introduction describing Tinderbox, she writes:

One of the preventive measures discussed in the book, male circumcision, has become an unexpected source of controversy. Anti-circumcision activists have hijacked Amazon.com’s “peer review” comments section, which allows readers to vote on which book reviews are helpful. This system has morphed into a vicious game of character assassination by conspiracy theorists who reject decades’ worth of scientific evidence, showing how easy it is for a concerted crusade to squelch good science.

My first response is to ask if Ms. Banerjee has ever been on the Internet before researching this piece. I mean that only partially in jest. This is how every comments section works, with few exceptions. The primary focus for blame here is probably in the design of Amazon’s peer review system, or at least in anyone placing any significant value on its worth in 2012 as the criterion for buying a book with a controversial topic.

She seems to understand this later in her article, which makes her unfocused back-and-forth attack on opposition to circumcision feel more like an agenda than a critique.

Where does all of this leave us? Two diligent and dedicated authors spent years researching the origin, spread, and potential prevention of AIDS in Africa. Two minutes and a few clicks were all that was required for a passionate extremist group to obfuscate and delegitimize their findings in front of one of their most important and public audiences. Having failed to prove their beliefs through scientific evidence, the intactivists decided to have circumcision, and this entire book, judged in the court of public opinion. Unfortunately for the public, this jury was rigged.

If all it takes is “two minutes and a few clicks”, that’s a flawed system, however inappropriate the action motivation’s may be.

She’s ignorantly inflammatory in her article because she does not appear to understand opposition to circumcision. It is not “extremist” to argue that potential benefits learned through adult volunteers do not negate concern for the ethics of applying that science to healthy, non-consenting individuals (i.e. minors). For some reason she never addresses this aspect of the debate. If she were interested enough to become informed, she could’ve challenged this behavior without misstating the facts about opposition to circumcision.

That said, there is a legitimate problem with this strategy. It’s inappropriate. We can do better. The full set of facts are on our side, and we should always act like it.

But, as problematic as this is, it isn’t as widespread as she declares with her bizarre, broad attack. Most who are against non-therapeutic child circumcision do not engage in this behavior or condone it from those who do. The title states that an “anti-circumcision fringe group” participated in this without naming any group. The group is somehow all “intactivists”. That’s irresponsible, bordering on the same type of unfair maligning she criticizes. She writes later in her article:

Although male circumcision occupies less than 10 percent of the book’s pages, it was enough to spark outrage among a tiny but passionately vocal fringe group, many of whom call themselves “intactivists.” They argue that the procedure is a grave human rights violation and are lobbying to ban the procedure in many countries.

Let me be clear: I do not support what happened on the Amazon page for Tinderbox. I didn’t participate. I don’t recall seeing anything resembling an attempt at an organized tactic. I recognize a couple names among those attached to 1-star reviews, and at least one name attached to a 5-star review, but that’s it. The correct way to state the facts here is that a small group of individuals have done this. It is incorrect, and defies common sense, to suggest that those who engaged in this constitute the entire group of people who oppose circumcision (of healthy children), as Ms. Banerjee’s sloppy accusation does.

Look at the numbers, which are no doubt now influenced further (in both directions) by Ms. Banerjee’s article. Consider this sample of the helpful ratings for one star reviews:

  • 91 of 232
  • 83 of 215
  • 81 of 212
  • 124 of 342
  • 76 of 277
  • 52 of 221
  • 33 of 197

Now consider this sample of the helpful ratings for five star reviews:

  • 114 of 129
  • 104 of 133
  • 111 of 151
  • 131 of 186
  • 73 of 135
  • 76 of 165
  • 101 of 153

They look similar¹, right? That’s not to minimize or dismiss (or legitimize) the gaming of the system. And voting down many of the 1-star reviews is probably appropriate. But it can work both ways. Amazon’s review system allows those who support the book to vote down a 1-star review on the basis of it being a 1-star review, without regard for its content. One seems more likely than the other, of course. Reasonable analysis and criticism must still start with the system, not its users. Where the users are wrong, the problem should be identified without hyperbole.

That last rating is also interesting because it’s the rating on the review left by Ms. Banerjee in June.


It’s really too bad that the reviews here have been taken over by an ideological group that shuns science and hard fact. This group has mobilized hundreds of people to write bad reviews and then rate their friend’s bad reviews as helpful.

The reviews (by people who obviously haven’t read the book) are really about their opposition to male circumcision, not about the content of the book at all. Which is pretty nonsensical, seeing as how the majority of legitimate public health institutions (including the World Health Organization and UNAIDS) have accepted that voluntary medical male circumcision prevents HIV by over 60%, and long term data shows it protects by 76%! That’s better than even the flu vaccine- so it’s surprising that these ideological quacks would rather let Africans die from a preventable disease than admit they don’t understand science.

Anyway, READ THE BOOK! There were (sic) always be quacks and naysayers out there (akin to those who still oppose the measles vaccine because they think it causes autism). The racist attacks on the author in these reviews do nothing to bolster their credibility!

I haven’t rated Tinderbox because I haven’t read it. I’ve skimmed it to get a feel for its treatment of circumcision. I have an unfavorable opinion about it based on that, but skimming isn’t enough to rate it.

She has read it. That doesn’t excuse that she engaged in nonsense in her review, as she also does now in her current article. It’s odd to suggest that “hundreds” of people are rating the book down when the number that could be attributed to opponents is obviously under 100. Exactly one 5-star review has more than 100 “unhelpful” ratings, and that one belongs to Professor Brian Morris, who engaged in the same sort of unhelpful ad hominem evidenced in Ms. Banerjee’s article. The math doesn’t add up to this being widespread among all intactivists, unless she honestly believes opposition to circumcision consists of fewer than one hundred people. The population who would do this probably is that small, but she painted opposition with the broadest brush possible, as she inexcusably does in her current Slate article.

It’s also silly to assume one has to shun science and hard fact to oppose non-therapeutic child circumcision. I don’t shun either science or hard fact. My position is that there are probably flaws in the methodology, but I don’t worry about them in my position because the correct position starts with present health and the ethics involved in consent. I assume every potential benefit is real, including reduced female-to-male HIV transmission in high-risk populations with low circumcision rates. But I am not a utilitarian who ignores individual rights, including the rights to bodily integrity/autonomy and self-determination. The right to be free from unwanted – and critically in this case, unnecessary – harm supersedes every potential benefit until the individual can weigh in with his personal preference on which he values more, the benefits or his foreskin. Where public policy or Tinderbox limits itself to voluntary, adult circumcision, I have no issues. The former rarely does, to its great discredit. The latter appears to follow the same pattern. For example, in Note 18 on page 352, Timberg and Halperin write:

… There has also been some confusion caused by mistaken comparisons with “female genital mutilation,” which is a very different type of procedure and can have serious negative medical consequences. …

This ignores the science and hard facts of male circumcision. Non-therapeutic genital cutting on a non-consenting individual is unethical whether it’s forced on a girl or a boy. Gender doesn’t matter here because all people, including male minors, possess the same basic human rights equally. That’s the ethical principle being ignored. That must stop.

Timberg and Halperin mistakenly imply that male circumcision is innocuous. All non-therapeutic genital surgeries have negative medical consequences for the individual that he or she may not want. (e.g. loss of foreskin, severed nerve endings, damage to/loss of frenulum) And some number of males have serious negative medical consequences, including partial or full amputation, as well as death. Perhaps they discuss this in the book. From my review of the indexed circumcision segments, I’m not convinced they take this into account. (During my prior reviews of Halperin’s work, most notably in this two part series on an awful paper to which he attached his name, I’ve seen no evidence that he assigns any weight to these facts.)

Continuing with Note 18 on page 352:

… Further confusing the issue of male circumcision are the protests of a small but vocal community of activists who often call themselves “intactivists” because of their belief that the male genitalia should remain entirely intact. This constituency has launched aggressive campaigns, including one that resulted in getting an initiative on the ballot in San Francisco to ban the performance of any circumcisions on minors in the city. California officials later ruled that cities had no authority over medical proceduress (sic). …

Neither I nor anyone I know believes that the male genitalia should remain entirely intact. That’s too simplistic and unconcerned with hard fact. I believe my gentials should have remained intact because I was healthy and my foreskin belonged to me. I believe every other male child’s healthy penis and foreskin should also remain intact until he may choose for himself, even if he ultimately chooses circumcision. The issue is bodily integrity and autonomy, not opposition to circumcision full stop. The San Francisco ballot initiative would’ve prohibited the performance of any circumcision on healthy, non-consenting minors in the city, not “any circumcisions on minors”. Omitting key words incorrectly frames the discussion and dismisses valid ethical (and scientific) concerns.

It’s also indefensible to engage in ad hominem (i.e. “ideological quacks” who “would rather let Africans die from a preventable disease than admit they don’t understand science”), as Ms. Banerjee does, without understanding the necessary qualifiers. Personally, I think everyone should use condoms because they prevent the transmission of HIV. If the adult male is so inclined, he may also volunteer to undergo circumcision. I don’t want anyone to die from HIV, but I don’t want anyone’s rights violated in a condescending good faith effort to force on him what someone else thinks he should want. If Ms. Banerjee wants to limit the discussion to voluntary adult male circumcision, that’s fine. She fails to explicitly limit the application of the science to the bodies of adult volunteers. From what I’ve read of Tinderbox, Timberg and Halperin fail to do so, as well. They should all recognize that they’re ignoring the ethical distinction between voluntary adult circumcision and non-therapeutic child circumcision.

Since this is indirectly a critique of Tinderbox, consider another footnote, note 18 on page 385.

… Meanwhile, some critics have suggested that male circumcision is similar to “female genital mutilation’ because it allegedly also reduces sexual functioning and pleasure. Unlike male circumcision, however, these practices-particularly the most extreme forms such as infibulation-can pose significant health risks for women. …

They’re repeating their error, treating male circumcision as if it carries an irrelevant risk of serious complications. But circumcision also changes the form of the penis, which changes the function. The mechanics are different. Maybe that’s better, maybe it isn’t. It’s unique to the individual, contrary to the majoritarian argument they’re about to make.

… In the rigorous studies that have investigated male circumcision’s effect on sexual pleasure, (115-28) nearly all men and their female partners report that after men become circumcised sexual pleasure is the same or enhanced, for both partners. During the 2005-2006 Swaziland pilot circumcision program mentioned in chapter 26, many women began saying that after getting circumcised their partners could have sex longer before reaching orgasm. Some of the clinic nurses reported that women would use metaphors such as, “He used to go from here [Mbabane] to Manzini [a city half an hour’s drive away], now he can go all the way to the border.”

Source 123, “Sensation and sexual arousal in circumcised and uncircumcised men”, states:

It is possible that the uncircumcised penis is more sensitive due to the presence of additional sensory receptors on the prepuce and frenulum, but this cannot be compared with the absence of such structures in the circumcised penis.

They (unintentionally?) demonstrate as much in their footnote, if only they were interested in the issue. The conclusion is that (voluntary, adult) circumcision doesn’t damage sexual pleasure because it is the same or enhanced for nearly all men and their female partners. So? This dismisses the diminished sexual pleasure for those outside the “nearly all” group. Those individuals matter, and no one should expect them to be mollified because another male is happy with his circumcision.

This approach is also based on “heads I win, tails you lose”. Circumcision is the same or better, and men can have sex longer. What logical reason can we think of that might explain lasting longer? Maybe this is good, but sexual pleasure involves a degree of individual preference. Not all males (or females) will want or need sex to last longer to enjoy it to the maximum extent for themselves.

Ms. Banerjee endorses this flawed argument in her article:

Although tens of thousands of men who were circumcised as adults and were studied in several large-scale clinical trials (and in a Slate series) reported no loss—and in many cases an increase—in sexual pleasure and function, the intactivists claim that male circumcision is equivalent to female genital mutilation, a practice whose purpose is to constrain a woman’s sexuality and impair sexual function. In one of its worst forms, a pre-teen girl’s clitoris and entire external genitalia are cut, scraped, or burned out, which can cause severe pain, infection, life-long incontinence, obstructed labor and delivery, and even death. To be truly equivalent, one would have to cut off a man’s entire penis in order to produce the same effect, rather than a small flap of skin.

First, that Slate series was ridiculous. I refuted it here and here.

Second, the possibility that one person might not like being circumcised as a healthy child exposes the ethical problem that she fails to address. Male circumcision involves control, and can be intended to directly impair sexual function. (It definitively alters sexual function.) Most forms of FGM result in far more harm than a typical circumcision, but civil law recognizes no level of acceptable harm from non-therapeutic female genital cutting, including forms less harmful than male circumcision. One does not have to remove the entire penis to produce the same effect that is legally prohibited for female minors. Male circumcision is not acceptable because FGM is usually worse. Even if the foreskin should be viewed as a “small flap of skin”, it is the male’s small flap of skin. Self-ownership rights do not disappear because possible benefits exist from a non-therapeutic surgical intervention.

Where she challenges the appropriateness of the comments attached to Tinderbox’s Amazon page, Ms. Banerjee is correct. Where she expands that into an indictment of any position against circumcision, she stumbles. There is more to the application of science to healthy individuals, whether adults or minors, than just a limited subset of science and hard fact. No male’s healthy body is a platform for expressing another’s personal preferences and fears, whether those of parents or technocratic public health officials.

¹ Sampled on September 26, 2012, except for the rating on Ms. Banerjee’s review. I updated that today because I kept the link.