Category: Science

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.

Valid Dinner Table Topics: Ethics

When I listen to podcasts discussing circumcision, I’m prepared to sigh and grumble in frustration. Listening to The Dinner Table podcast: Circumcision involved a different experience. I talked pointedly at my radio as I listened, pausing every 30-45 seconds to digest my irritation. It was generally an unpleasant experience because the discussion needed much more reflection and thought in place of the talking-point regurgitation. However, I’m glad I stuck with the episode. It contains numerous succinct examples of both exactly why we shouldn’t circumcise children and how people encounter truth but manage to pick themselves up and scurry off before having to confront reality.

Note: I’ve kept the conversational tics in the transcript from the hosts, Tessa Osborne and Griffin Wiles. (I will do this for their interview with Dr. Joel Greenberg, which I’ll review in my next post). I left them in because they demonstrate the speaker working through the thought in real time, which I think is fairer than editing it. I do not interpret or intend these tics within the transcript to suggest anything else.

Here are some observations:

Wiles: Mmm hmm. And there’s, of course, there’s hygiene. People who are not circumcised as a child, and later on in life, get circumcised, it’s a hygienic reason. If they do it themselves, or if parents circumcise their kids… … or if parents circumcise their kids, it’s for hygienic reasons. Adolescents and young adults are more likely to be circumcised. Social and sexual desirability are also really big social determinants in being circumcised.

Boys should and can be taught to wash themselves. Surgery is neither a replacement for nor an ethical change to this basic life skill.

The next section in the podcast covers some of the perceived medical benefits. I’m not interested in refuting them in detail again here, so I’ll both point to my archives and reiterate that every possible benefit argued for can be achieved and/or treated with less invasive methods and with the consent of the individual himself. That’s the core of the topic, not whether or not imposing it on someone can achieve something.

Anyway, in my experience, the perceived medical benefits are the cloak of respectability placed over the real reason, which is some variation of “I like it, aesthetically”, which Wiles states directly. It’s also, “women prefer it”. Or, more crudely, “women won’t have sex with him if he’s not.” It’s the cultural lie society repeats without questioning whether or not it’s true. If it were true, as people pretend, we don’t stop to consider that maybe the individual male would rather have his foreskin than sexual attention from someone for whom he is not good enough without surgical modification.

After a bit more about the perceived benefits making risks “significantly” lower, a statement that isn’t true in the context of absolute risks (or when compared to less invasive alternatives):

Wiles: … Along with the medical aspect, a lot of people think that circumcision diminishes sexual pleasure, or that it diminishes sexual desire, and there is little evidence that supports the theory that sexual function and sexual desire is diminished. So, really,…
Osborne: Good to know.
W: … the studies are inconsistent in the results that they yield…
O: Mmm hmm.
W: … so there’s really little evidence to suggest that circumcision has an impact on sexual desire and sexual function, period.

There is ample evidence that circumcision diminishes sexual function. Even studies cited favorably by circumcision advocates demonstrate the undeniable truth that the foreskin has nerves (e.g. ridged band and frenulum) and functions (e.g. gliding mechanism). Circumcision removes both. It’s objectively incorrect to conclude anything else with regard to function¹.

Moving to the ethical question reveals a missed opportunity for contemplation on the primary question involved:

Osborne: I want to know, what do you think ethically about circumcision?
Wiles: Alright, well. Personally, I grew up circumcised, was circumcised very early on.
O: Can I go as far as to ask you, are you still circumcised to this day?
W: I am still circumcised, it did not grow back.
O: Ok.
W:
O: Just the way you had made it sound, you were like, “I *was* circumcised. I *was*.”
W: I was at a time circumcised, yeah. So I… … I thought that all penises looked like circumcised. I thought penises were, they just came circumcised, like I didn’t know it was a whole procedure until later on in life. I’m glad I was circumcised, I have to be honest, I am glad, because I think aesthetically, for one circumcision makes the penis look more attractive.
O: Mmkay. Have you ever met a guy that said that he didn’t want to be circumcised?
W: I’ve met guys who are uncircumcised but I have never asked if they want to be.

Ponder that last question more, please. It’s what matters here, as the intact guys can still choose. (If it isn’t obvious, I’m a guy who doesn’t want to be circumcised, but I had no choice in the decision.)

Osborne: Ok. How do you feel about, like, if, you know, if you gave a child that choice, like you decided not to circumcise them, and you said, like, if when they’re an adult, and they want to do it, they can do it. Do you think that’s, like, right, or do you think…
Wiles: I think that’s…
O: …….. or do you think, just do it when they can’t feel it?
W: I think that’s right, umm. I do feel like there are advantages to doing it when they are younger, especially with the disease prevention and the convenience. If you’re already in a hospital, you might as well.
O: Ok, I… I, personally, under the topic of genital… … mutilation, if we could call it that. I wouldn’t… like, if I had a son, I wouldn’t want to make that decision for him. I don’t think that’s fair for me. Umm… I think that might be violating some of his rights. And I think that he can do it when he’s older. I mean, we’ve got good medicine, he can be knocked out, get it done.

“You might as well” is not an ethical argument. It is a pithy shorthand for the abdication of parental responsibility for which so many people justify circumcision.

Last, while Osborne’s overall approach is strong, I don’t understand the assumption within “when they can’t feel it”. Babies can feel pain, including after the procedure during healing. I doubt she believes babies don’t feel it, and this was a thinking-out-loud shorthand for “can’t remember it”. If so, that has its own problems, as any thought experiment would show we can do all kinds of awful things to babies that they won’t remember. Not remembering them wouldn’t make any of them ethical to impose.

There’s still an interview to analyze, but that will get its own post.

________________________________________________
¹ In the linked study, Bossio found that the foreskin is the most sensitive part of the penis to light touch, which seems clearly relavant to the typical sexual experience. It’s absurd to find this objective fact and then explore subjective explanations valuing only other aspects. Some men will value other aspects more, yes, but some won’t.

Or, as the linked article by Brian Earp explains:

So let me try another analogy. Saying that removing the foreskin “doesn’t reduce penis sensitivity” is a bit like saying that removing the pinky finger doesn’t reduce hand sensitivity. What you really mean is that removing the pinky finger (which is part of the hand) doesn’t reduce sensitivity in the remaining fingers—although, as we’ll see, it’s not even clear that this part of the analogy holds up in the actual study.

In other words, it’s an odd way to frame the hypothesis. To continue the analogy, my guess is that most people—if faced with the claim that removing the pinky finger doesn’t reduce sensitivity of the hand—would say, “But what about the pinky finger itself?!”

Flawed Circumcision Defense: Wesley J. Smith (Again)

I expect garbage opinions on male circumcision. Too many people don’t think about it, letting the inertia of ignorance fill in the gaps in their knowledge as parents (and humans pondering anatomy). But I don’t expect such trash from a magazine like National Review that prides itself on being smart, honest, and principled. (More on that in a moment.) Here, Wesley J. Smith shows an embarrassing lack of curiosity and imagination. (Again, since Smith has shown he doesn’t understand the subject before.)

“Intactivists”–the nutty name anti-circumcision activists have given themselves–who aim to outlaw infant circumcision, claim that the procedure has no benefits and constitutes child abuse.

Baloney. There are at least mild health benefits for men, to the point that the American College of Pediatricians recommends that the choice of whether to circumcise be left to parental discretion.

He should talk to more people against non-therapeutic male child circumcision, since he doesn’t appear to have met those like me. The procedure has potential benefits. Removing a body part inherently means something that can happen to it can no longer happen. Phimosis, for example, is no longer possible. Or name any potential benefit, real or made up. It doesn’t matter. Smith cites a new rehashing of studies by Brian Morris¹ showing potential benefits to the health of female sexual partners. Fine. I’ll concede it, even though much of the context is often dropped. Male circumcision offers that benefit, whether it does or not.

Here’s the problem: so what? That something is possible does not prove it’s acceptable to do it. Acceptance of science (with disagreement on the veracity of claims) is compatible with rejecting the application of that science to the healthy, normal body of another human being without that person’s consent. Non-therapeutic male child circumcision does not meet the ethical threshold for proxy decision-making. It can be delayed until the male can consent, given that it’s non-therapeutic. There are less invasive prevention methods and treatments available for every potential issue non-therapeutic circumcision seeks to address. The child owns his body, including his foreskin. This is the same human right everyone has over their body and genitals.

That’s all before we even get to preference. What does the individual want for his body? All tastes and preferences are unique. The individual has to live with the decision. If left intact with his choice, he has to live with it for 18 years, at which time he can change it. Or not. If circumcised, he has to live with it for the rest of his life, including the decades he’ll spend as an independent adult. He can’t reject what didn’t need to be forced. The ethical difference in those two scenarios is stark.

Notice, too, that Smith can’t even cite the right organization, calling the American Academy of Pediatrics the American College of Pediatricians. The latter exists, but is not the source² of his link. If he can’t cite them correctly, what is the likelihood he read the AAP’s technical report that fails to support their position?.

Smith concludes:

The utter obsession some have about outlawing circumcision–whether undertaken for religious or health reasons–has always puzzled me.

But now we know that other than emotion and a bizarre belief expressed by some intactivists that sex isn’t as good for the circumcised, there appears no substantial reason to oppose the practice, much less outlaw it.

If he addressed his puzzlement with research rather than cognitive dissonance and confirmation bias, he might understand there’s more than BUT MUH BENEFITS. That Wesley J. Smith can’t think of a reason against non-therapeutic child circumcision is not proof there is no reason against it. The reasons are real and substantial.

For example, he would know the “belief” expressed that sex isn’t as good for circumcised men is an argument that sex isn’t the same, which is a fact, and that it likely isn’t as good, an educated guess based on data and anecdotal evidence. Removal of the foreskin means sex with a circumcised penis is sex without a foreskin. If you change form, you change function. The skin and nerves and functionality there at birth are no longer there. Again, that is a fact. Whether that’s good or not is a different matter. And again, all tastes and preferences are unique.

Anecdotal opinions are easy to find, but you have to be willing to search for and understand the implication of “…[n]ever felt I was too sensitive before circumcision but in retrospect I was.” Will every man think he was “too” sensitive? Does that suggest circumcision changes sex, at least?

Or do you need someone with a few more credentials, such as Dr. Laura Berman, who states “[r]emoving the foreskin also removes thousands of nerve openings that make sex more pleasurable.”

Or do you want a scientist and ethicist who studies circumcision, like Brian Earp, who reads studies rather than headlines to understand what research means. This includes when he read and analyzed³ a study by Jennifer Bossio, writing⁴, “you will be surprised to learn—I am quoting directly from the paper now—that ‘Tactile thresholds at the foreskin (intact men) were significantly lower (more sensitive) than all [other] genital testing sites’ including the sites in circumcised men (emphasis added).”

Or do you want another researcher who studies circumcision and sensitivity, like Dr. Kimberly Payne, who wrote in her study, “[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.”

Yet, Brian Morris used Payne’s study, which he rated as the highest quality, in another rehash he used to conclude, “the highest-quality studies suggest that medical male circumcision has no adverse effect on sexual function, sensitivity, sexual sensation, or satisfaction.”

The people who seem to care the least about the details of circumcision generalize toward the view they already held going in. Morris is a propagandist, and presumably Smith relies on him because he wants to believe. He’s not unique in that approach, but it’s not something he should put on display as he did.

Which leads me back to National Review’s Credenda. Among their convictions:

A. It is the job of centralized government (in peacetime) to protect its citizens’ lives, liberty and property. All other activities of government tend to diminish freedom and hamper progress. …

Non-therapeutic child genital cutting, including circumcision, violates the rights of the child, who is an individual and a citizen. Removing his foreskin deprives him of his property and liberty.

It is appropriate for the government to prohibit the non-therapeutic circumcision of male minors, as it already does for female minors. Whether or not that’s the fastest path to ending the cultural abomination is worth discussing. I think it isn’t, unfortunately. But it’s an appropriate legitimate action of government, since it would protect the rights of citizens, the substantial reason government exists. The government ignoring this diminishes freedom.

Whatever your opinion of National Review, Smith’s defense of circumcision should embarrass everyone at National Review.

¹ If you want to read the Morris study, follow the link to Smith’s post. If you want to know how to analyze one of the papers Morris cites in this new rehash, which is one of his previous rehashes of prior papers, read here and here. But notice the pattern of Morris rehashing papers over and over for the casual reader like Smith to think, “ahhh, a new study, and look at the volume of past studies showing the same thing!”. Stop being a dupe for his propaganda.

² The American College of Pediatricians has an official statement on Female Genital Mutilation. Its only reference to male circumcision is when it states:

The terminology itself has generated controversy. The World Health Organization emphasizes the fact that there are no medical benefits associated with even the least invasive procedure. Therefore, the WHO uses the term ‘mutilation’ to “establish a clear linguistic distinction from male circumcision, and emphasize(s) the gravity and harm of the act. Use of the word ‘mutilation’ reinforces the fact that the practice is a violation of girls’ and women’s rights, and thereby helps to promote national and international advocacy for its abandonment.“ (source)…

That linguistic distinction is propaganda, in the definitional, non-pejorative context, which the end of the quote acknowledges. There is harm in genital cutting, regardless of the victim. The practice is a violation of the victim’s rights, regardless of the specific genitals of the victim.

Yes, FGM is usually worse than male circumcision. Not always, and the law against FGM in the United States do not permit those harms equal to or less harmful than male circumcision. We treat the issue differently depending on who the victim is, which is logically and ethically flawed. The presence or absence of potential benefits is irrelevant to both. The absence of both need and consent is all that’s relevant.

³ Predictably, Brian Morris mischaracterized this finding in another of his rants.

⁴ Earp also clarifies with an analogy:

“Saying that removing the foreskin ‘doesn’t reduce penis sensitivity’ is a bit like saying that removing the pinky finger doesn’t reduce hand sensitivity. What you really mean is that removing the pinky finger (which is part of the hand) doesn’t reduce sensitivity in the remaining fingers — although, as we’ll see, it’s not even clear that this part of the analogy holds up in the actual study.”

Lazy thinking seems to be a prerequisite for those who advocate non-therapeutic male child circumcision.

False Distinction, Not False Equivalency

Note: I’m not going to write about the charges directly here. Anything involving a cursory glance of my work here will let you know I understand, abhor, and reject FGM in every form. If guilty of the charges, the doctors should serve the maximum sentence allowed.

I noticed something both fascinating and infuriating in this USA Today version of the Detroit Free Press article on the arrest of three doctors in Michigan on charges of mutilating the genitals of female minors. Specifically, this section:

As some medical experts on the topic stated in a 2015 article by The Atlantic:

“Male circumcision does no harm. Female gender mutilation does. Male circumcision cuts the foreskin, FGM cuts the clitoris — the two things cut are not even remotely the same. For male circumcision to be equivalent to FGM, the entire tip of the male’s penis would need to be cut off … Constantly trying to claim they are equivalent practices when they are not takes away from the unique seriousness of female ‘circumcision/mutilation,’ as most cases are performed during a traumatic developmental period and remove most sexual sensation, which is not true with male circumcision.”

Two things immediately jumped out. Who are the medical experts? Where is the link to the Atlantic article? Seeing that this is the USA Today version, I investigated to determine if the link was dropped from the original Detroit Free Press version, which is here. Nope. The link isn’t there. And not only is the link not there, those two paragraphs were removed and replaced. (More on the latter in a moment.) So I checked the Wayback Machine to see if the USA Today version is different or out-of-date. Predictably, it’s out-of-date, because the first version was what USA Today still presents. My hunch was that the reporter, Tresa Baldas, (or an editor) made an inexcusable mistake, which was then erased (incompletely, because the internet is mostly forever). It’s the conclusion I draw, but I’m open to more facts.

I found the referenced Atlantic article, “How Similar Is FGM to Male Circumcision? Your Thoughts”. It contains Baldas’ paragraph from two excerpted, merged comments. The quoted “medical experts” are a commenter called Tyfereth and a commenter, Jim Eubanks, who is an MD candidate, according to his Facebook profile. Half-right, I guess, except the initial comment is the one drawing the alleged distinction. Tyfereth’s comment:

Male circumcision does no harm. FGM does. Male circumcision cuts the foreskin, FGM cuts the clitoris, the two things cut are not even remotely the same. For male circumcision to be equivalent to FGM, the entire tip of the males penis would need to be cut off. Now that would be a harm, but cutting off the foreskin isn’t harmful.

This is ridiculous logic. (It is also incomplete knowledge of the various types of FGM.) Cutting inflicts harm. This is indisputable, except for foolish attempts such as this. Declaring that cutting the body and removing a normal, healthy body part is somehow harmless, like touching a raindrop, should raise skepticism in every reporter (and editor). That it didn’t immediately demonstrates a problem Ms. Baldas (and/or her editor) should question in her continuing coverage. Instead, she quoted Tyfereth as a medical expert on nothing more than a lame “nuh-unh!”.

At least Mr. Eubanks appears to be closer to an expert. But he isn’t making the same argument, so he shouldn’t be lumped in with Tyfereth’s nonsense. In his complete comment, he’s a bit more nuanced.:

False equivalency. You can stand against both practices, but constantly trying to claim they are equivalent practices when they are not takes away from the unique seriousness of female “circumcision/mutulation” as most cases are performed during a traumatic developmental period and remove most sexual sensation, which is not true with male circumcision. We can oppose both but take them on their own terms please.

He’s still wrong, of course. There is no false equivalency in the principle. Non-therapeutic genital cutting on a non-consenting individual is unethical. The right involved is a human right based in consent, not a female right based in degree of harm¹. The cutting done on an individual is a matter for penalty, not whether both violations or just those of females should be treated as crimes. The boy who is cut has as much right to his normal, healthy body² as the girl who is cut has to hers.

This is apparent with analysis of a more recent article Ms. Baldas wrote, “Report: Girl’s genital mutilation injury worse than doctor claims”.

A doctor’s findings, however, contradict that claim. A juvenile protection petition filed on behalf of the victims in Minnesota, along with federal court documents, cite scarring, a small tear, healing lacerations and what appears to be surgical removal of a portion of her genitalia.

I have or had all four of those injuries. I can’t state they are to the same degree, of course, so I’m not declaring that here. I’m stating the comparison is valid because non-therapeutic genital cutting without consent violates the individual. There is no false equivalency in stating that everyone has the same right to be free from unneeded, unwanted harm.

————-
Here are the paragraphs that replaced the reference to the medical experts in the Atlantic.

Medical associations also have cited health benefits to male circumcision, but have found no such benefits to female genital mutilation, which has been condemned by medical organizations worldwide.

For example, The American Academy of Pediatrics and the U.S. Centers for Disease Control have both found that the health benefits of newborn male circumcision outweigh the risks, though both groups say the final decision should be left to the parents as it may involve religious or cultural beliefs. The benefits cited by both groups include the prevention of sexually transmitted diseases, including HIV, and a lower risk for urinary tract infections in infants.

Neither group, however, endorses female genital mutilation in any form and has cautioned physicians against practicing it. The same goes for the World Health Organization, which has condemned female genital mutilation, but has recognized health benefits to male circumcision, stating: “There is compelling evidence that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%.”

First, the “FGM has no medical benefits” argument is a false distinction. It’s true, but irrelevant in the comparison. Most, if not all, opponents do not oppose FGM because it has no medical benefits. They oppose it because it violates the girl and inflicts harm on her. It’s a “spaghetti against the wall” argument. If researchers were to find (potential) benefits, the harm would still be real. Few opponents would change their mind. Rightly, of course, but it demonstrates the argument’s irrelevance.

Next, the American Academy of Pediatrics did not “find” that the health benefits outweigh the risks. They declared it to be true in the same way Michael Scott declared bankruptcy. The ethics section (Pg. 759) of its 2012 technical report states:

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

This is obviously true. The value of a potential risk reduction at the expense of risk and an objective physical cost with the lost foreskin is a subjective conclusion based on the individual’s personal preferences. Yet the Abstract misrepresents what’s in the Technical Report when it declares, “preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure”. The AAP knows this is not a factual statement. Lazy, uncritical journalism perpetuates this subjective conclusion as fact.

Even the alleged bioethicist involved in the Task Force knows the truth, despite what he signed off on with the Abstract. Dr. Douglas Diekema said, “Not everyone would trade that foreskin for that medical benefit.” All individual tastes and preferences are unique. I think the potential benefits probably have merit. I don’t care. I don’t want them in exchange for my foreskin. I’d rather have my foreskin and a (tiny) higher absolute risk of a foreskin-related problem than my circumcision. This is true in spite of my parents preferring me circumcised. The proper analysis is cost-benefit, not risk-benefit. The risks are a relevant cost, but the loss of the foreskin is the primary cost of circumcision. For indefensible reasons, most – including the AAP and CDC – ignore it completely.

The reference to the CDC is curious for another reason. Its proposed guidelines have not proceeded beyond the flawed draft recommendations from 2014. Again, uncritical journalism is probably to blame. Most treated the draft as final, despite it clearly stating “draft” and open to review. I assume this happens due to laziness and confirmation bias. Insert your own theory why. It doesn’t matter. The result is misinformation spreads further.

With respect to FGM, the AAP briefly proposed a ritual nick as an alternative, which has implications for the “false equivalency”. But it is correct they don’t endorse it today. The WHO, however, is clueless and/or hypocritical. From its FGM factsheet, it states:

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.
…

FGM has no health benefits, and it harms girls and women in many ways. It involves removing and damaging healthy and normal female genital tissue, and interferes with the natural functions of girls’ and women’s bodies. Generally speaking, risks increase with increasing severity of the procedure.

Everything there that isn’t the “spaghetti against the wall” argument (and “total removal” for the pedants, although it occurs) is true of male circumcision. WHO recognizes FGM as “a violation of the human rights of girls and women”. It is a violation of human rights, not female rights. Injury to the genitals without need or consent is the problem, not the form of the body part.

¹ Even though, yes, what is done to females is usually more harmful than what is done to males.

² This applies to intersex children, too. Obviously.

Flawed Circumcision Defense: Barbara Kay

[10/19 Update: Edited for clarity and to reduce speculation since late night posting is imperfect and probably unwise.]

National Post columnist Barbara Kay used Brian Morris’ latest rehash on circumcision to repeat her ignorant thoughts on the subject. She begins by regurgitating claimed benefits, which can all be conceded here for the sake of time because they’re irrelevant to the only issue, ethics. Then:

… Dr. Morris and his American co-authors state, “We found that up to 65% of uncircumcised males might experience at least one of these [medical conditions] over their lifetime.” …

Until May 2015 Morris claimed the number as 33%. Since June 2015 he claims it’s 50% in a brochure on his website. And it’s apparently 65% in this new review. When will he settle on 100%? But more to the point, it’s obvious he likes whichever way he can claim this number because it’s flashy. “Ooooooh, 33/50/65 percent is high. Such danger!” But it’s a meaningless number in the context of non-therapeutic circumcision of boys. I assume Morris knows this. I assume Kay doesn’t, so a review of Morris’ history could help. Instead of those numbers, this is what is worth discussing here, from Morris:

Up to 10% of males reaching adulthood uncircumcised [sic] will later require circumcision for medical reasons.

Not only is the number only 10%, it’s only up to 10%. Medically necessary circumcision is rare, at any age. There is no ethical case for imposing the most radical solution without consent when at least 90% of males will never need it.

She continues:

… Their risk-benefit analysis of the procedure led them to conclude the benefits exceed the risks by about 100 to one. (In another study, published in the Journal of Sexual Medicine, Dr. Morris and colleagues found circumcision produced no adverse affect on sexual function or pleasure, a charge often leveled by anti-circumcision activist groups.)

Much like when Yair Rosenberg accepted Morris’ claim unexamined, Kay doesn’t appear to know the primary source.

But in a study Morris and Krieger rate as [highest quality], Payne et al [12], this:

… 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. …

Payne’s study published in 2007. In 2011 Kay wrote:

Set aside the rights-based rhetoric. It’s about sex: Circumcised men have greater pre-orgasmic endurance; non-circumcision permits more frequent ejaculations. …

So, circumcision either delays orgasm, assumed to be positive for all men, or has no effect on sexual pleasure. Like Morris, she appears to play “heads I win, tails you lose”.

Kay goes on to write:

… The AAP states: “The new findings 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.”

That quote is not from the AAP. It’s from Prof. Morris. He wrote it in a press release more than 18 months after the AAP published its revised position statement. Kay doesn’t bother to fact check the most basic statement. [ed. note: Kay asked the online editor to correct her error.] Nor does she pursue how Morris’ quote undermines their case for non-therapeutic neonatal circumcision since he acknowledges that circumcision is rarely necessary.

Thus, while it’s inexcusable, it’s hardly shocking when she continues:

The CPS could not condemn the practice on grounds of increased morbidity. After thousands of years of what is essentially a controlled study with virtually all Jewish men, with a large percentage of Muslim men on one side, and uncircumcised men on the other, it has been unequivocally concluded that circumcision presents no health risks; quite the contrary, as we shall see.

Even Morris doesn’t pretend that circumcision “presents no health risks”. He understates them, and ignores the guaranteed harm from the removal of the foreskin (and possibly frenulum) in 100% of circumcisions. But he’s not so biased that he’ll posit such an obvious untruth. Yet, there’s Kay’s indifference masquerading as hyperbole for all to see.

… Morris’s team estimates the combined frequency of adverse events at 0.4% overall, arguing that “the cumulative frequency of medical conditions attributable to [having an intact foreskin] was approximately 100-fold higher” than the cumulative risk of circumcision.

Even if we accept the numbers, he’s arguing frequency of medical conditions attributable to the foreskin, not the frequency of medically necessary circumcision. It’s fascinating, perhaps, but a transparent obfuscation. The anti-science charge is often leveled at activists here, but soap, water, antibiotics, steroids, condoms, and so on are also science. To start with the most extreme solution at the tiny prospect of a problem sometime in the future is ridiculous.

When she gets to the comparison of male and female genital cutting, she ignores the principle.

The single most irrational argument one often sees is the charge of moral equivalency between circumcision and female genital mutilation. FGM is a phenomenon that is, apart from both affecting the genitals, …

Apart from both affecting the genitals, indeed. Affecting the genitals of a healthy child who does not need or consent to the permanent alteration of said healthy genitals. Non-therapeutic genital cutting on a non-consenting individual is unethical. The individual has inherent rights to bodily integrity and autonomy from birth. Non-therapeutic circumcision violates those rights.

… quite separate from circumcision. Unlike circumcision, which removes an unnecessary piece of skin, …

Unnecessary circumcision removes a piece of skin. It’s the same words, but made objective rather than subjective. It’s the fact-based opposite of “heads I win, tails you lose”.

… in no way prevents natural and satisfying sexual function, …

In addition to calling back to the Payne study and Kay’s earlier comments about delayed orgasm, circumcision removes the foreskin, a natural part of the body. That is “natural”. Its mechanism is gone, so circumcision certainly prevents that function. And “satisfying” is subjective. Would all men prefer delayed orgasm and the loss of the foreskin? (I don’t.)

… FGM is a misogynistic practice created as a means for men to control women, …

Circumcision controls men. Its imposition is another’s assessment that the male’s body should be the way someone else prefers. It is then made that way (hopefully, except when complications occur, including possible death). The male is never asked. He is to say “thank you”, praise the imposition, and impose it on his sons as soon as they’re born.

Kay’s argument rests on control as intent rather than action. I doubt she would accept that parents cutting their daughter’s genitals for the reasons we allow them to cut their son’s genitals. She assumes their intent is always evil, but is it the intent or the act that matters here? If she believes intent with FGC is only what she writes, as she appears to believe, she should read more¹ on the topic. And then extrapolate back to the disparity in the intent and the violence of male circumcision.

… meant to prevent sexual desire and gratification in women to ensure their fidelity, and which removes a portion of the genitals absolutely vital to gratification. It is the very epitome of patriarchy, whereas circumcision is a rite of passage conceived by males for other males, and for thousands of years rooted solely in spiritually contractual language and meaning. Women who have been subjected to FGM invariably come from countries in which extreme misogyny is the norm. Circumcision carries no moral or gender-injustice baggage of this kind whatsoever.

I agree that FGM is awful. But it’s silly to repeatedly claim a definitive knowledge that male circumcision does not remove of portion of the genitals absolutely vital to gratification. She ignorantly cites bad summaries of studies and only uses groups of males circumcised at birth or as young children as reference points for this opinion. She doesn’t appear interested in males as individuals with rights and preferences of their own for their foreskins. (“Conceived by males for other males”.) Preference for the foreskin or circumcision is an individual decision. What other males prefer is only valid for themselves.

She closes by misunderstanding the ethics involved one last time, in a disgusting manner:

Parents deserve to be informed of all the evidence, pro and con, when the issue of circumcision arises. It is not necessary for the CPS to actively recommend circumcision to keep to the path of ethics and professional responsibility, but given the accumulation of evidence demonstrating the positive effects of circumcision, it would be unethical of the CPS – or any pediatricians individually – not to present the science available, or worse, to recommend against the procedure.

She’s dancing close to the silly proposition that boys have a right to grow up circumcised. The only ethical position is absolute opposition to (and prohibition of) all non-therapeutic genital cutting without the patient’s consent. It’s the right she recognizes for females. Her source (inadvertently?) recognizes that circumcision is rarely needed ever and can be (but likely won’t be) chosen later. She cites evidence of males who are dissatisfied with circumcision and being circumcised. But she ignores these in favor of her own biases. Cognitive dissonance (and a non-sequitur) is the best she can offer. She is ignorant. She should aim to be less ignorant.

¹ Consider Fuambai Sia Aahmadu, and from 2008.

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.

Flawed Circumcision Defense: Karin Klein

Encouraging half-baked opinions, like this one by Los Angeles Times reporter Karin Klein, is the inevitable result of the CDC’s proposed recommendation. The opinion piece is titled, “It’s time to end inaccurate criticisms of male circumcision”, which suggests its author should not offer an incomplete analysis in defense of male circumcision. That is what Ms. Klein offers.

The recent report by the U.S. Centers for Disease Control and Prevention should quell the unfounded arguments that male circumcision is no better than or different from female circumcision, also known as female genital mutilation. According to the draft guidelines released by the CDC, the benefits of male circumcision clearly outweigh the risks, in the form of reduced risks of urinary tract infection as infants and penile cancer later in life, and lower risk of contracting HIV and other sexually transmitted diseases.

The short version of her essay is “Shut up.” It’s her introduction and conclusion. Alas¹, no.

“According to the draft guidelines released by the CDC” involves undue weight for the recommendation. The CDC’s conclusion is subjective. The equation is not merely benefits versus risks. There is a direct cost (i.e. harm) in the loss of the foreskin. That matters, yet it isn’t factored into the CDC’s analysis (or the AAP’s before it or Ms. Klein’s here). And the CDC ignores the individual foreskin owner’s preferences. Someone might value his foreskin more than reduced risks of future maladies. As I do. It isn’t defensible to declare that the potential benefits “clearly” outweigh the risks, for everyone, or that this demonstrates anything conclusive.

The comparison of male circumcision to female genital mutilation rests on the principle involved, not indifference to the disparity in recognized potential benefits. Non-therapeutic genital cutting on a non-consenting individual is unethical. Minimal or maximal cutting is relevant for punishment, but not for whether the individual’s human rights are violated. A female owns her body from birth, including her genitals. A male owns his body from birth, including his genitals.

It’s understandable that circumcision has become controversial. It’s a permanent change made to the body, usually in infancy. (It should be noted that parents make all kinds of decisions that affect their children’s lives permanently; circumcision happens to be a particularly visible one.) …

It’s a permanent change made to the healthy body. Defending this removes any limitation on what parents may do. It isn’t that it’s a particularly visible effect. It’s that circumcision alters the child’s body without need. Proxy consent requires the patient’s need, not the proxy’s preference. Non-therapeutic circumcision is still cosmetic surgery, contra the silliness Ms. Klein will shortly suggest.

Nor is non-therapeutic circumcision acceptable because parents make all kinds of decisions. This common argument rests on the flawed premise that a) Parents make decisions for their children, b) Non-therapeutic genital cutting is a decision, therefore c) Parents may cut the healthy genitals of their children sons. It’s ridiculous. Treating all decisions equally to defend an extreme, gendered decision makes no sense. It imagines a strange scope of parenting we don’t accept, as evidenced by the required strikethrough in c) to narrow the conclusion to what parents may legally decide on non-therapeutic genital cutting. It’s about parental rights only to the convenient extent that it maps to what we want to do. It’s arbitrary.

The CDC report won’t end the debate, nor should it necessarily do so. Perhaps its most important short-term good will be to increase the likelihood that the procedure will be covered by health insurance, because circumcision could not be viewed as solely a cosmetic procedure, but rather one that carried health benefits backed by the most current scientific research. That gives parents the option — either way.

It is still cosmetic surgery, even with potential health benefits backed by the most current scientific research. It is backed by an incomplete analysis of all factors involved. Arguing only from potential benefits and risks without factoring in the costs (i.e. harms), as well as preferences for how an individual weighs those three aspects for himself, is biased, inaccurate nonsense. The CDC shouldn’t peddle it. Ms. Klein shouldn’t defend it.

But it should end the scurrilous argument that male circumcision, with its very low complication rate, is mutilation on par with female circumcision. There are no known health benefits to female genital circumcision and a long list of not-uncommon consequences, including fistulas, abscesses and childbirth complications.

If Ms. Klein is going to use a word like scurrilous to criticize critics, she should first understand mutilation. Should we assume that a case of non-therapeutic female genital cutting without the girl’s consent that doesn’t result in a complication, or at least only a “very low complication rate”, isn’t actually mutilation? I assume Ms. Klein’s answer is the correct answer, which is “obviously not”. We can also search for the unifying principle that shows how weird it is to argue that parents should have the choice to surgically alter the bodies of their children, except this choice is for sons only because we’ve researched that. For example, in the WHO factsheet on Female Genital Mutilation, this:

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.

Partial removal or other injury to the genital organs for non-medical reasons? As long as you don’t foolishly suggest “reduced risk of X” is somehow a medical reason² for non-therapeutic circumcision, removing the foreskin is clearly such an injury.

And:

FGM has no health benefits, and it harms girls and women in many ways. It involves removing and damaging healthy and normal female genital tissue, and interferes with the natural functions of girls’ and women’s bodies.

Removing and damaging healthy and normal genital tissue, and interferes with the natural function of bodies? Male circumcision fits that, too. Without need or consent, male circumcision is indefensible genital mutilation. Awareness of potential benefits does not change the equation. It is mere question-begging.

Of course, even religious traditions shouldn’t outweigh health concerns. Just as female genital mutilation is outlawed in this country no matter what the religious beliefs of the parents, if the CDC report had found similar complications with male circumcision, then there should be serious conversations about whether the procedure should be allowed. But that’s not what the science shows; until there is solid evidence to contradict the CDC report, conversations about restricting parents’ ability to make this decision for their sons should end.

It makes sense to ask if the boys who suffer the complications, including the most serious outcomes, could be considered mutilated, or is it merely based on the intent we assume for the parents? (The simplistic, “Male genital cutting is well-intentioned. Female genital cutting is ill-intentioned.”) But complications and consequences are unique. Consequences includes the costs (e.g. loss of the foreskin). That ignored aspect is what makes non-therapeutic male circumcision an unacceptable parental choice. Again, using the subjective conclusion that the benefits outweigh the risks while excluding the factual harms and the child’s preference is an incomplete analysis. Demanding, as Ms. Klein does, that we guide policy on this subjective opinion is ludicrous.

The CDC’s recommendation and Ms. Klein’s demand aren’t made better by using SCIENCE! as an incantation. Ã… normal, healthy foreskin is science. The numerous methods short of circumcision to prevent and/or treat maladies are science. A condom is no less SCIENCE! than circumcision. Antibiotics are no less SCIENCE! than circumcision. Soap and water are no less SCIENCE! than circumcision. It might be interesting that parents prefer SCIENCE! to SCIENCE!, but the issue involves ethics. The ethics are the same, whether it’s daughters or sons. Non-therapeutic genital cutting on a non-consenting individual is unethical. We all have the same basic rights. Non-therapeutic genital cutting without the individual’s consent violates her – or his – basic human rights.

¹ The piece includes a “Shareline” suggestion to tweet out a link to it with propaganda, “There are reasonable debates about male circumcision — but not about its benefits vs. risks”. That’s also nothing more than “Shut up”. It poisons the conversation by setting boundaries on what’s “reasonable” to debate. It’s also incorrect.

² The factsheet makes it clear that this would not be accepted for any non-therapeutic female genital cutting, as the law against FGM in the United States also makes clear. There is a principle, and it doesn’t negate the principle of equal rights simply because we’ve agreed to study the possible benefits of cosmetic surgery.

Science is more than intervention

This thread fascinates me. I read as much as I could stand and was repeatedly amazed at the logic and tactics, especially those from self-professed “skeptics”. It’s also a useful insight into why I don’t use Facebook for activism. (To those who agree with me that non-therapeutic child circumcision is unethical, please don’t engage in the vitriol and name-calling in this thread. It’s wrong and hurts our efforts.)

In response to a picture (used without permission) of a man holding a sign¹ explaining his opposition to circumcision, the moderator for a group called “I fucking love vaccines” posted this:

Those evil “doctors”!!111! Performing minor operations on infants in sanitary conditions with proper pain relief, giving the lifelong benefits of prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV. A procedure that would be significantly more complex and painful for an adult male.

If that’s a skeptic’s analysis, skepticism means nothing. Discussion of non-therapeutic child circumcision needs a thorough cost-benefit analysis because that is appropriate for proxy consent and demonstrates the ethical failing, not just the question begging of the benefit recitation provided above.

In response, a pediatrician² responded with a deeper analysis:

So I have to disagree with the sentiment here. I am a Board-Certified Pediatrician. When we look at the benefits of a procedure, we need to consider the Number Needed to Treat (NNT). In other words, how many boys do we need to circumcise to prevent one case of…something?

For HIV in the highest-prevalence regions of Africa, the answer is 72. 72 circumcisions must be done to prevent one case of HIV. That number hasn’t been calculated in the US, but with our much lower HIV prevalence and the fact that HIV in the US is primarily transmitted by anal intercourse, the number would be orders of magnitude higher. Even for unprotected anal intercourse, the NNT is over a thousand. For UTI in the United States, the answer is 200-300. For penile cancer the number ranges into the millions.

I can show that routine appendectomy reduces the risk of acute appendicitis by 100% and that routine tonsillectomy reduces the risk of tonsillitis by 100% and yet we don’t routinely perform either. So why are we performing a mutilating procedure on infant boys on a routine basis? It’s the only such elective operation we do. It flies in the face of medical ethics that we perform routine circumcisions on infant boys. And for that reason, I refuse to do them.

And yes, it’s mutilating. That isn’t a judgmental or emotionally-charged term in my usage. Any procedure that changes the appearance of the body is mutilating. That includes a medically necessary appendectomy. Now, I would never argue against a medically necessary appendectomy, but the key words are: “medically necessary.” Circumcision isn’t. And the proof is Europe, Asia, Australia, and New Zealand where these things aren’t done and yet their overall epidemiology for related conditions stay the same.

I do agree, however, that equating circumcision with female “circumcision” or “rape” is insulting to people who have been subjected to these things. I find that absolutely disgusting that any man would equate his circumcision to rape and complete excision of the clitoris.

I disagree that equating male and female genital cutting is insulting. The comparison is more complex than and focused on principle than “removal of the male prepuce is the same as removing the clitoris.” Non-therapeutic genital cutting on a non-consenting individual is unethical. That’s the principle. Everything else in the doctor’s comment is spot-on.

The moderator replied to the last paragraph:

Yeah, that is my issue with this actually and the whole reason I posted it. This does nothing but trivialize male violence against women.

Then why not post about that relevant issue instead of providing the one-sided, non-skeptical benefit recitation? But that isn’t the curious response. This is:

I also remain skeptical of your claims of being a pediatrician when you come into a socially charged thread never having commented on my page before and going against official recommendations in the US, but no biggie.

This is embarrassingly free of skepticism. It’s skepticism as a label rather than a process. I’m supposed to trust someone offering only the benefits of a non-therapeutic surgery on a child when that person can’t be bothered to do even a minimal amount of research to confirm a commenter’s identity? It took me about 60 seconds to find evidence that the Facebook profile matches a real person who is a pediatrician. This does not prove that the Facebook profile isn’t an elaborate scam to post biased, misleading comments on a random Facebook community’s rant. It could be, but that seems to require a few too many (convenient) assumptions.

Anyway, his job title is interesting, but there’s more than just an appeal to authority. Google exists for more than just verifying a random doctor’s identity. Does what he wrote hold up? Number Needed to Treat is a topic anyone can research. Is he explaining it correctly? Are his numbers accurate? What are the implications to the question of non-therapeutic child circumcision? But maybe I’m wrong and a skeptic doesn’t need all the information.

Of course, the moderator seems to value the appeal to authority fallacy. Better still would be to read the AAP’s technical report to see what it omits instead of merely regurgitating the inadequate abstract. I read the technical report. It is lacking.

Also, the “official” recommendation is that parents should decide, not that circumcised males are incorrect if they’re unhappy.

Next is a string of comments from people who don’t seem to understand that words have meaning and should be applied in a way consistent with their definitions. For example:

Consent is given by the parents. It is not forced when the parents give consent on their son’s behalf.

And:

Because the surgery is for the benefit of the child not to create harm. The use of the term “mutilation” is hyperbole to generate a negative emotional response. This dishonest technique is used by intactivists because the facts do not support their position.

Parents consent. The surgery is forced on children who do not consent. This is not complicated. It’s the essence of proxy consent. The question is whether that consent is valid on this topic. And the surgery is not harmless and cost-free merely because the parents don’t intend to do harm. I agree they don’t intend harm. But harm is inevitable, despite their intentions.

Nor is the use of the term “mutilation” hyperbole. The doctor made the case, but here it is in the context of another post from the moderator:

There were of course the inevitable hysterical people saying circumcision of infant males is equal to FGM, most of which occurs in the developing world in unsanitary conditions, and which offers ZERO health benefit, serious long term health complications and is considered a violation of the human rights of girls and women. There is no comparison between circumcision and FGM.

I am seriously skeptical of the skepticism of a lot of these commenters on what is supposed to be an anti-woo page are caricaturing medical doctors as being “savage” and “barbarians”… this is no better than what people against “Big Pharma” and the “Medical Establishment/”Western” medicine/Allopathy caricaturize doctors as.

I am offended by it and I do not even have any family members in the healthcare professions. Here is a link to some fact these hysterical/testerical dimwits should know about or stop ignoring.

http://www.who.int/mediacentre/factsheets/fs241/en/

*The procedure has no health benefits for girls and women.*
*The procedure has no health benefits for girls and women.*
*The procedure has no health benefits for girls and women.*

Not only do you show your lack of scientific understanding but you also engage in vile misogyny when you compare to FGM, a HUMAN RIGHTS VIOLATION to basically harmless infant circumcision.

That link is full of gender-neutral principles arbitrarily assigned a gendered difference. When the WHO states that “[i]t involves removing and damaging healthy and normal female genital tissue, and interferes with the natural functions of girls’ and women’s bodies”, we can ask ourselves if we’d dismiss that if its preceding sentence stated “FGM has health benefits…” I believe the overwhelming response would be “no”, as it should be. Change the pronouns. The principles remain the same. Genital cutting without need or consent is mutilation.

I also invite anyone to read through my archives to see if I’m a dimwit who doesn’t know about or who ignores the facts about FGM.

More on mutilation:

Except that circumcision is not an act of physical injury that degrades appearance or function, so once again, your own definition does not support calling circumcision mutilation.

Assuming the perfect form comes at birth is rather ridiculous when you consider evolution does not select for perfect. If the foreskin was perfect there would have not been the need to make surgical improvements starting several millennia ago.

“Degrades appearance” is subjective to the individual circumcised. That it degrades function is not up for debate, or at least not that it alters function. If you change the form, you change function.

The evolution bit is mere question begging. There is no “need” to alter healthy genitals. Evolution didn’t screw up. Most males (and females) live normal, healthy lives with their prepuce. And notice how circumcision becomes a “surgical improvement”. It’s always “heads I win, tails you lose” on every subjective question.

Next comes the tired false dilemma fallacy about how only one side loves science:

You would advocate against a procedure with medical benefits? OK. I admire your honesty in admitting that even though it makes you look like a callous jerk.

“Why do you want babies to get UTI-laden HIV Cancer, you monster?” Except, that’s not the only choice or the only (or likely) outcome from leaving a child with all of his (or her) normal, healthy genitals.

Finally:

the big mean doctor touched my wee-wee!

“[T]he big mean doctor touched my wee-wee with a scalpel without medical need” is the scenario. If you must offer unfunny ridicule, at least attempt to ridicule what’s happening. That’s if this community’s form of skepticism involves facts, which I’m unconvinced it does.

¹ I’ve made my opinion clear on the accuracy and value in calling circumcision “rape”. I stand by that here.

² I’m not using names here because they’re irrelevant for my purpose here. Click through the links, if you wish.

Some of us wouldn’t dream of having any procedure

There is an inherent flaw always present in “parents should decide on genital cutting (but only for boys)” essays. An asinine dismissal of the ethical principle will exist. Although the case against must be made each time, the ethics obviously do not support that stance. Non-therapeutic genital cutting on a non-consenting individual is unethical. It violates bodily autonomy. Any facts supposedly in favor of at least allowing parents to decide can’t overcome this basic principle. So when an essay is titled “Why the decision to circumcise should be left in the hands of the family”, the flaw is guaranteed to be there. It’s the only way to seemingly make the premise hold. Yet, I’ve never seen the flaw so ridiculously written as in Dr. Jeremy Friedman’s essay.

Deep into the essay (emphasis added):

I understand that there are many vocal groups who feel that circumcision has a negative effect on sexual function and pleasure. I also realize that some feel it is unethical to remove something from an infant’s body without a clear medical need and without the infant having some input into the decision.

As a pediatrician, I’m not really professionally qualified to discuss the merits of these viewpoints but I respect the right of those individuals to express them. I am, however, qualified to tell you that babies are capable of experiencing pain and I don’t think it is acceptable to perform a circumcision in a newborn without some form of analgesia. There are a number of different options to prevent pain, and this should be discussed with the practitioner chosen to do the procedure, well ahead of the circumcision.

Dr. Friedman stated that he’s not professionally qualified to discuss the merits of these viewpoints, yet this is the next paragraph, his conclusion:

So what is my take-home message? The decision should be left in the hands of the family. Current medical evidence points to some specific advantages to being circumcised, especially in certain higher risk groups. In Canada I’m not convinced that there is sufficient medical evidence to advocate for circumcision in a family that would not choose it for religious/cultural/family reasons. Nevertheless in those who do choose it, I think they should be allowed the right to proceed, but I will put in a plea for encouraging adequate pain relief. Let’s face it: None of us would dream of having any procedure on this rather sensitive part of our anatomy without it.

He can’t evaluate the validity of individual autonomy for a human being, but he’s qualified to draw a conclusion without concern for the effect on his conclusion from the ethical claim he did not test. That’s pathetic. It isn’t acceptable to punt an aspect of the debate and then claim victory. It’s more ridiculous because he felt competent to draw an ethical conclusion on pain relief. It’s a minor distance from a plea to use pain relief to a plea to refrain from medically-unnecessary circumcision.

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In a paragraph aimed at defending parental choice because a study claims the complication rate is lower for newborns, he wrote:

… My interpretation of this data is that when circumcision is performed by adequately trained individuals, complications are infrequent and usually fairly minor. Most common would be infection and bleeding which can be treated quite easily. Nevertheless severe complications such as penile injury can occur, albeit very rarely. If one wants one’s son circumcised then it appears to be much safer if done in the newborn period.

Penile injury occurs in every single circumcision. Less severe penile injury isn’t irrelevant simply because it was intended.