Renee Lute’s Circumcision Decision Deserves No Respect

Posted: October 11th, 2013 | Author: | Filed under: "Voluntary", Control, Ethics, FCD, FGM, Logic, Media Marketing, Pain, Parenting, Science | No Comments »

At The Good Men Project Renee Lute makes a request: Please Respect Our Circum-Decision. It only requires a short response: No. Still, her essay is worth analyzing to explain why the only answer is “no”.

Circumcision on a healthy child is a permanent body alteration without the child’s consent. I’m under no obligation to respect that. I do not believe anyone should respect that. If Lute understood circumcision as well as she claims, she’d understand how absurd it is to request respect for her decision from someone who recognizes this surgical intervention as the human rights violation it is.

She is, of course, due a respectful rejection of her request. I will not engage in ad hominem, nor will I call her names as a result of what she intends to do. Anyway, facts and logic are enough to demonstrate her errors.

She begins:

… I’m apologizing to [my unborn son] for writing this piece, because now the world will know just a little bit about the future state of his penis, and most little boys don’t have to deal with that. …

This common theme is strange. Intact genitals are the human default. Unnecessary intervention is the only reason the status of a child’s genitals is considered an issue if people know, as if knowing is a Big Deal. Or, rather, unnecessary intervention is the only reason the status of a boy’s genitals is considered an issue if people know. This bizarre reality is the result of intervening, not some inherent shame in having others know we have human genitals.

That gets to the reason why I won’t respect her and her husband’s decision for their unborn son. A daughter’s normal, healthy genitals are off-limits for surgical intervention, and rightly so. Those who recognize the ethics involved as gender-neutral must stand against the opinion that a son’s normal, healthy genitals can be subjected to surgical intervention. (There will be more on the valid comparison below.)

She discusses Mark Joseph Stern’s terrible Slate piece (my post) and Brian Earp’s reply at The Good Men Project. She writes:

Neither of these articles really threw me. I know the arguments against circumcision, and I know the arguments for circumcision. What did surprise me, however, was what I found in the comments section under The Good Men Project article. …

Never read the comments. We know that doesn’t mean “never read the comments”. But it’s a reminder that the Internet is a place for bad manners and emotional responses. That’s particularly true in comment sections. Discussion of circumcision is no different. I’m not excusing the behavior. The rude, hateful, and misogynistic garbage is wrong and needs to stop. But reasoned proponents of bodily integrity, as I aim to be, have our argument harmed only in the sense that someone is willing to generalize about those who disagree based on the miscreants that any group has.

… I am not a circumcision enthusiast. In fact, I could not care less whether other people circumcise their sons or not. Do it if you want! Don’t if you don’t want! But I am begging you—begging you—to not make families who choose to circumcise their sons feel like they are abusers of children, or human rights violators.

“Do it if you want! Don’t if you don’t want!” is the false argument. What does the child who will live with the circumcision want? That is the core. Without knowing what he will want, imposing it as a non-therapeutic intervention is a human rights violation. I suppose it’s unfortunate if that makes someone feel bad about circumcising their healthy son(s). But I recognize that my parents violated my rights when they circumcised me. I won’t pretend¹ that someone else circumcising their son isn’t violating his rights because stating a truth makes them feel bad about the choice they make. (I do not take a position on how individual males should feel about being circumcised.)

Why am I going to have my son circumcised? Because his father and I have done our reading. We’ve talked about it, and we’ve made our decision. There are legitimate reasons. Circumcision eliminates the risk of phimosis (in which a foreskin is tight and cannot be fully pulled back, which makes cleaning and passing urine difficult, and increases the risk of penile cancer). This affects 1 in 10 older boys and men. Circumcision reduces the risk of inflammation and infection of the head of the penis and the foreskin, and greatly reduces the risk of urinary tract infections in infants. Uncircumcised men have a 15-60% increased risk of prostate cancer (which affects 1 in 6 men). [1] We are not uneducated about circumcision. …

That last line is not necessarily true, given what comes before it in that paragraph. The sole source cited for this knowledge is a pamphlet by Brian Morris, which contains no sourcing of its own. (Some of the material in this excerpt is verbatim from Morris, without quotes to indicate as much.) It contains information that is biased and exaggerated.

To the claim that circumcision eliminates the risk of phimosis, this is incorrect. Contrary to the risk of phimosis being a “legitimate reason” to circumcise a healthy child, the ethical standard is that the risk of complications is a legitimate reason to refrain from intervening on a healthy child. Remember, too, that Brian Morris is the cited source for the 1 in 10 claim. He’s stated that all boys are born with phimosis, which is false. Even if the statistic is true, it is that phimosis will affect 1 in 10, not that it will require circumcision in 1 in 10. This mirrors his claim in the pamphlet that “the foreskin leads to 1 in 3 uncircumcised boys developing a condition requiring medical attention.” A condition requiring medical attention is not a synonym for circumcision. This is a rhetorical sleight of hand. The true incidence of medical need for circumcision within an intact male’s life is approximately 1%, which includes for phimosis.

As for the “15-60% increased risk of prostate cancer” statistic, that is a correlation, not a proven fact. “Circumcision before first sexual intercourse is associated with a reduction in the relative risk of PCa in this study population.” To quote the author, “‘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.”

She continues:

… One of the aforementioned commenters wrote that anyone who would have their child circumcised should have to experience it themselves, first. Well, my husband has experienced it (and remarkably, he gave me his permission to tell the world just now), …

I don’t like that pointless suggestion because it invites that pointless rebuttal.

…and while I have not gone through the completely incomparable horror of female circumcision (I am not going to detail why it’s incomparable here, but I do encourage you to research the differences if you don’t know what they are. You’ll find some information here), …

I know what the differences are. I know what the similarities are. The difference is in degree, not in kind. That difference in degree can be great, of course, but non-therapeutic genital-cutting on an individual without the individual’s consent is not a gendered principle. The WHO defines female genital mutilation as “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.” The perceived difference², including in the link Lute provides, rests on what constitutes a medical versus non-medical reason. If we assume the “no known health benefits” argument against FGM turned into “known health benefits”, would people change their mind and decide it’s no longer mutilation? Some might say “yes”. They’d be wrong. I suspect most people would not change their conclusion. As the WHO states, FGM “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.” That would still hold true if their were potential benefits. It holds true for male circumcision, as well.

… My husband and I aren’t unfamiliar with pain, and we are willing to put our child through a moment of discomfort for the benefits this procedure provides. Kind of like we’re willing to put our child through a moment of discomfort for the benefits that vaccinations provide.

But is their child son willing to have the moment (i.e. 1+ week) of discomfort and a lifetime without his foreskin for the potential benefits this procedure provides? (Remember from above that the Lutes do not appear to understand the benefits.)

Circumcision is not like a vaccination. Vaccinations work with the body’s immune system to trigger disease resistance. Circumcision merely removes a part of the body because it might cause a problem later. The comparison needs critical thinking beyond “prevents disease”, lest we further open parental decision-making to other ridiculous interventions.

This piece is both explanatory and pleading. I am pleading with you. Don’t make these perfectly well intentioned families—like us—feel like monsters because you’ve decided to go a different way with your own sons. We’re doing something different, and that’s okay. We each have our reasons. I don’t care whether you breastfeed or formula feed. I don’t care whether you co-sleep or have your babies in their own cribs, and I don’t care whether you’ve named your child something completely traditional (like Kate) or whether she’ll be answering to Zenith for the rest of her life. I’m asking for the same courtesy.

It’s okay to do something different. It is not okay to do this something different. You can’t respect one right of your son less than the same right of his sister and brush it aside as “parenting”. If someone asks me to respectfully tell them they’re wrong, I agree with that request for decency. But I will not respect what is obviously indefensible and deeply offensive to basic human rights.

¹ I don’t call circumcision “abuse”. (c.f. Truth and Loaded Words)

² The other mistake is in thinking that FGM is designed to control sexuality, but that male circumcision isn’t and doesn’t. It controls male sexuality because it forces a specific form on the child for his genitals. (e.g. It’s more aesthetically appealing to women.)

There is also a history, up to the present, in circumcision reducing sexuality. Read Moses Maimonides or this.


With Friends Like These…

Posted: September 20th, 2013 | Author: | Filed under: Ethics, Logic, Parenting, Science | 1 Comment »

The provocative cliche in the title is a two-way argument. As it was in the AHA Foundation post, and as it is with the frustrating, losing argument comparing circumcision and rape, people can insist on behavior that risks their own credibility. There’s satisfaction in being right, but it’s a seductive mistake to assume that counts for anything. Advocacy is about changing minds. Advocacy requires meeting people where they are, not where one thinks they should be.

Jill Filipovic posted on Mark Joseph Stern’s smear in Slate. Her post is a mix of good and bad.

Every time female genital cutting is mentioned on Feministe — every time — someone from the “intactivist” community shows up to derail the conversation and make it all about the alleged horrors of male circumcision. Intactivists, for the unfamiliar, are men (and a few women) who oppose male circumcision. They claim it’s a violation of human rights, that’s it a physical mutilation, that it’s medically unnecessary and that it reduces sexual pleasure. They’re incredibly active online, and I was interested to see that they aren’t just trolling feminist blogs — they’re showing up in the comments of every article written on circumcision.

As I said in the AHA Foundation post, “those against forced male genital cutting need to be responsible when interjecting into a discussion on FGM/C, including by doing so less often.” Considerably less often, probably. That’s the key point in that paragraph and the one I hope people grasp first.

She leaves open the possibility that the negative behavior she mentions is limited to a few when she wrote “someone from the ‘intactivist’ community” rather than the intactivist¹ community. She makes this mistake in the comments when she writes, “Wait, you mean the intactivists come onto this thread and act like total misogynist assholes? Weird! No one could have predicated that.” A few people do not constitute “the intactivists”. This is the obvious mistake Mr. Stern made. “Never read the comments” is hyperbole, but there is truth in understanding that the comments are not the entirety of the debate. The conclusion against those who oppose non-therapeutic child circumcision is too generalized to be defensible. The way some people use an open forum irresponsibly isn’t indicative of what everyone believes or how they behave.

She continues:

It’s not that intactivists are wrong about everything. There should be a debate about circumcision, and there is something to be said for the position that it’s ethically wrong to remove a piece of an infant’s body where not necessary to preserve that infant’s life or health. It’s an interesting and important bodily autonomy question. On the one hand, from the strictest perspective, it seems wrong to circumcise a child without his understanding and consent. Yes, circumcision may have some disease-prevention benefits, but it comes with risks as well. On the other hand, parents do things all the time that violate their children’s bodily autonomy; they regularly don’t get their children’s consent on issues that impact that child’s person, and they even directly override their children’s desires. That’s part of being a good parent. Your kid may not want to get a vaccine, but you should probably vaccinate your kid. Your kid doesn’t want disinfectant on that cut, but the cut should get disinfected. Your kid wants to only eat hot dogs every day for the rest of his life, but your kid should probably eat some vegetables.

Circumcision is more serious than a cut and hot dogs, but the vaccination piece is perhaps comparable — it’s an irreversible medical intervention. Personally, I’m sympathetic to the arguments that circumcision is an unnecessary violation of bodily autonomy. Yet if I lived in a place with a high prevalence of HIV, I’d probably circumcise my kid, as recommended by the World Health Organization.

This is an additional reason not to be a jerk to her (or anyone). She’s got the gist. It’s still not acceptable to circumcise minors in areas with a high prevalence of HIV for all the easy reasons. The WHO recommendation is wrong and unethical. The studies only researched voluntary, adult circumcision. The existence of – and continued need for – condoms, as well as the possibility of better prevention or a cure before the child is sexually active, makes waiting for consent a basic requirement. Mr. Stern complained about intactivists not paying attention to studies. It’s not excusable that he made the same mistake by assuming that the studies are transferable to infant circumcision. But see how close Ms. Filipovic is to the complete principle. Being rude is unproductive, in addition to being impolite.

The other problem with talking about this issue with the intactivists who parachute into random comment sections to debate is their nasty habit of playing fast and loose with the facts. Mark Joseph Stern at Slate explains:

[Excerpt Omitted]

The whole piece is worth a read, because circumcision is certainly something worth discussing and debating. But all parties need to come into the conversation honestly. A philosophy or principle may be so correct that it outweighs a conclusion pointed to by the weight of scientific evidence. But then let the philosophy stand against that evidence. Twisting the facts and intentionally obscuring the truth doesn’t help in the parsing of difficult ethical issues.

That’s what I got at in my post yesterday on Mr. Stern’s piece. The observation that some people behave badly is relavent. It isn’t proof against the principle’s validity. His conclusion is too broad, and obviously so. There are honest people in the debate. If a few are to stand as the representatives for all, honest people will be smeared unfairly, as Mr. Stern did.

The debate isn’t just the philosophy standing against the weight of scientific evidence. There is scientific evidence on the side of the philosophy. The normal, healthy foreskin is normal and healthy. It doesn’t require intervention, especially not the most radical intervention. Soap is science. Condoms are science. Antibiotics are science. That isn’t twisting the facts or obscuring the truth. We must stop pretending those facts aren’t involved. We must stop pretending the burden of proof rests with those who advocate against surgery on healthy children.

Citing the HIV benefit, which I concede for the argument, involves stating the facts only if citing the rest of what WHO and the AAP say about its applicability. Ms. Filipovic did. Mr. Stern didn’t. Mr. Stern played fast and loose with the facts.

¹ I wrote this seven years ago.

I’m familiar with the term intactivist. It’s cute and descriptive, but because it’s cute, I do not like it. As the article shows, it does little more than give reporters an excuse to fill in the story with details at which typical readers will roll their eyes. That’s not helpful.

I still agree with it. I think its use here and in Mr. Stern’s essay show the danger in being able to label this way.


Mark Joseph Stern Is Mistaken On Circumcision

Posted: September 19th, 2013 | Author: | Filed under: "Voluntary", Ethics, FCD, FGM, Hygiene, Logic, Media Marketing, Parenting, Public Health, Science | 1 Comment »

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.


The AAP Discounts Its Patients’ Right to Physical Integrity

Posted: March 23rd, 2013 | Author: | Filed under: Ethics, FCD, Law, Logic, Parenting, Politics, Public Health, Science, STD, Surgery | No Comments »

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.”


Dr. Douglas Diekema: Still Inconsistent on Circumcision

Posted: March 10th, 2013 | Author: | Filed under: Ethics, FCD, Science | No Comments »

Inevitably, whenever a new study suggests that circumcision may not be a panacea of benefits without costs, dismissal follows swiftly. That isn’t the problem. Skepticism is always warranted, and sometimes, criticism is also warranted. I do wish more people, particularly journalists, would adhere to that when pro-circumcision studies are published, but c’est la vie. The facts are on our side in this (unfortunately) long effort. The key is getting to facts.

With the recent study confirming “the importance of the foreskin for penile sensitivity, overall sexual satisfaction, and penile functioning”, the refutations have begun. When Dr. Douglas Diekema criticizes, odd bouts of cognitive dissonance are almost guaranteed. Here, Dr. Diekema joins the rebuttal¹ to this study with his unique way of missing a much-needed chance for self-examination.

“The study is pretty flawed,” said Douglas Diekema, a pediatrics professor at the University of Washington, who was part of the American Academy of Pediatrics 2012 task force on circumcision. “I read the conclusion and then I read the study, and I said, ‘Wow, they went overboard in what they’re concluding.'”

If only Dr. Diekema, a member of the American Academy of Pediatrics (AAP) Task Force on Circumcision, always cared about having the details match the conclusion, with not going overboard in a conclusion. For example, in the AAP’s revised policy statement on circumcision, the technical report states (page 759):

… 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. …

That’s the core truth for any non-therapeutic intervention, which clarifies the ethical flaw in proxy consent for non-therapeutic circumcision. What does the individual who doesn’t need circumcision want for himself?

Yet, in the abstract for its revised policy, the AAP bizarrely concludes:

Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; …

The statements in the technical report and the abstract do not say the same thing. The details do not support the conclusion. The abstract states an opinion that the technical report makes clear is not universally true or applicable to any specific individual male. Dr. Diekema once stated (correctly) that “not everyone would trade that foreskin for that medical benefit.” Yet, he stands behind the revised policy that encourages proxy consent for non-therapeutic circumcision while maligns those who criticize the report for its obvious flaws. He’s made these contradictory statements for more than a year. At some point maybe he’ll stop doing that, or he could even embrace the ethics involved that require rejecting non-therapeutic genital cutting on a non-consenting child. I can hope.

¹ The study may be flawed, and perhaps in exactly the way Dr. Diekema states. I don’t wish to engage in confirmation bias merely because I like the findings. Anyway, I don’t need the study. The principled ethics matter more than whether circumcision is “good” or “bad”, both subjective to the individual foreskin owner.


Adult Circumcision Healing Time

Posted: September 29th, 2012 | Author: | Filed under: "Voluntary", Logic, Media Marketing, Science | No Comments »

I want to revisit the AAP’s technical report accompanying its revised circumcision policy statement. In the Ethical Issues section, on page 760, this:

… Parents who are considering deferring circumcision should be explicitly informed that circumcision performed later in life has increased risks and costs. Furthermore, deferral of the procedure also requires longer healing time than if performed during the newborn period and requires sexual abstinence during healing. …

This is so often repeated that it’s simply become the accepted truth about voluntary adult circumcision. It should be questioned¹. Does circumcision require a longer healing time in adults than if it’s forced on infants? Evidence suggests this is overblown, at best.

From a 1999 paper by Daniel T. Halperin, PhD and Dr. Robert C. Bailey, “Male circumcision and HIV infection: 10 years and counting”:

By avoiding this issue althogether (sic, medical professionals and public-health authorities may inadvertently be harming the very individuals whom they are trying to help. As increasing numbers of men and boys turn to circumcision as perceived protection from AIDS, many will be exposed to harm by untrained practitioners who use unsafe methods. Yet, contrary to some popular misconceptions, safe and inexpensive male circumcision is routinely performed in developing countries in clinical settings. The procedure is normally performed on an outpatient basis with local anaesthesia, and most men return to light work activities the next day.

From the Brian Morris et al. paper I didn’t like, in the “Absence from work or school” section on Page 10 (pdf):

Unlike the convenience of circumcising a baby that (sic) sleeps most of the time and is a dependent in society, circumcision during productive work or school years will typically require taking time off, although the amount of time off required is typically small. In one study of men circumcised with the Shang Ring device, men took an average of 1.1 days off work; 80% were back at work by day 2, with only 20% requiring more than 2 days, and little disruption to activities or discomfort was reported for the week the ring was in place [121]. Eighteen percent of men in the study reported disruption to their work while the device was present, and 30% had not resumed routine leisure activities by 7 days. In the large Kenyan RCT, only 4% of men required 3 days or more before they could return to normal activities [57]. In a study of childhood MC, median times of 5 days to return to normal activity and 7 to return to school have been reported [182]. This may have been because children are usually more active than adults, thus increasing the chances of injury and so prolonging the healing period.

It’s also interesting that the AAP’s claim is unsourced in the technical report. On what evidence do they claim that adult (i.e. deferred) circumcision requires a longer healing time than infant circumcision? It doesn’t seem to be an accurate statement.

¹ The claim that it costs more should also be questioned. If nothing else, the time value of money must be factored in. The several hundred dollars saved now (that will accumulate) must be compared to the present value of the future cost. The unlikelihood of needing circumcision must also be included. If adult circumcision costs 10x more but is only performed in 8% of males, the net effect is that it’s cheaper. No results from such an analysis would change the sufficient ethical argument against non-therapeutic infant circumcision.


Joya Banerjee Misunderstands Opposition to Circumcision

Posted: September 27th, 2012 | Author: | Filed under: "Voluntary", Control, Ethics, FGM, HIV, Logic, Media Marketing, Public Health, Science | 3 Comments »

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.


Odd AAP Advice on Penile Development and Care

Posted: September 14th, 2012 | Author: | Filed under: Ethics, Parenting, Public Health, Science | No Comments »

Adding to my post on ethics, I want to continue with the recommendations from the technical report on non-therapeutic male child circumcision issued by the AAP Task Force:

  • Parents are entitled to factually correct, nonbiased information about circumcision that should be provided before conception and early in pregnancy, when parents are most likely to be weighing the option of circumcision of a male child.
  • Parents of newborn boys should be instructed in the care of the penis, regardless of whether the newborn has been circumcised or not.

Notice the past tense in the second point. Parents should be instructed in the care of the penis before they decide to circumcise. My anecdotal experience suggests some number of parents circumcise in part because they don’t understand how to care for a normal penis. However small this number probably is, if parents shouldn’t be ignorant, the AAP should recommend education before the decision, not after. Some parents may leave their son his choice if they’re educated in how simple and non-scary it is to care for a normal, intact penis.

It should also provide factually correct information. From “Care of the Circumcised Versus Uncircumcised (sic) Penis” (Pg. 763):

Parents of newborn boys should be instructed in the care of the penis at the time of discharge from the newborn hospital stay, regardless of whether they choose circumcision or not. The circumcised penis should be washed gently without any aggressive pulling back of the skin.24 The noncircumcised (sic) penis should be washed with soap and water. Most adhesions present at birth spontaneously resolve by age 2 to 4 months, and the foreskin should not be forcibly retracted. When these adhesions disappear physiologically (which occurs at an individual pace), the foreskin can be easily retracted, and the whole penis washed with soap and water.25

No, they should be instructed about care before discharge. Even if we ignore the obvious point that a circumcision would likely already have been performed by that point, are parents not responsible for any care for their son while in the hospital? Unless a hospital is doing it wrong, they don’t just keep the child until parents are discharged and then say “here you go”.

More importantly, that paragraph contains factually incorrect information. The Task Force states that most adhesions present at birth spontaneously resolve by age 2 to 4 months, which is ridiculous. It’s also unsupported by their source. From footnote 25, Caring for the uncircumcised penis: what parents (and you) need to know by Cynthia J. Camille, FNP, CPNP, Ramsay L. Kuo, MD, and John S. Wiener, MD:

Penile growth, along with intermittent erection, aids in the process that eventually completely separates the prepuce from the glans to form the preputial space (Figure 1). This process begins late in gestation and proceeds at varying rates during childhood; therefore, the age when the prepuce is completely retractable also varies.2,3 Complete retraction past the corona is possible in at least 90% of boys by 5 years of age. In contrast, some boys will not have complete separation of the prepuce circumferentially beyond the corona until accelerated penile growth occurs at puberty.

Even if “90% by age 5” is correct (some evidence at this link suggests it might be an overestimate), that differs significantly from “by age 2 to 4 months”. This is a recipe for incorrect diagnoses of phimosis and forced retraction, leading to unnecessary circumcision for non-existent medical necessity.

If we look at source 24, the AAP’s Caring For Your Son’s Penis, it states:

The Uncircumcised Penis

In the first few months, you should simply clean and bathe your baby’s uncircumcised penis with soap and water, like the rest of the diaper area. Initially, the foreskin is connected by tissue to the glans, or head, of the penis, so you shouldn’t try to retract it. No cleansing of the penis with cotton swabs or antiseptics is necessary, but you should watch your baby urinate occasionally to make sure that the hole in the foreskin is large enough to permit a normal stream. If the stream consistently is no more than a trickle, or if your baby seems to have some discomfort while urinating, consult your pediatrician.

The doctor will tell you when the foreskin has separated and can be retracted safely. This will not be for several months or years, and should never be forced; if you were to force the foreskin to retract before it is ready, you could cause painful bleeding and tears in the skin. After this separation occurs, retract the foreskin occasionally to gently cleanse the end of the penis underneath.

The Task Force provided no obvious evidence to support its “by age 2 to 4 months” claim. Either they didn’t correctly source the claim they made, or they’ve allowed at least one mistake to enter the document. Neither generates much confidence in the overall process.


AAP Circumcision Policy – Flawed Ethics

Posted: September 12th, 2012 | Author: | Filed under: "Voluntary", Control, Ethics, FCD, HIV, Law, Logic, Media Marketing, Parenting, Politics, Public Health, Science, STD | 7 Comments »

Much has already been said on the flaws in the AAP’s revised policy statement on non-therapeutic male child circumcision. (Here’s an additional plug for the exceptional rebuttal by Brian D. Earp.) I want to comment directly on its recommendations and the ethical issues addressed – or unaddressed – in the technical report. First, from page 757:

The Task Force made the following recommendations:

  • Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it.
  • Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.

These two statements conflict. Stating that the benefits outweigh the risks is a judgment call based on subjective valuations of the various inputs. The task force recognizes this when acknowledging that some parents would value other considerations more than the AAP’s evaluation of the net effect. That same possible difference of opinion applies to the cost-benefit analysis itself, which should include actual costs (i.e. the foreskin) rather than just risks.

The AAP is stating that it’s possible to disagree with the task force, but only to an extent because it reviewed the data and drew a conclusion. That’s wrong because the evaluation requires subjective weightings rather than objective criteria. It’s one thing to question the possible benefits altogether, as some do. It’s also possible to accept the potential benefits while not valuing them more than the costs involved. All individual tastes and preferences are unique. AAP Circumcision Task Force member Dr. Douglas Diekema said as much prior to the release of the revised policy statement. Why is that not reflected here in place of this incorrect statement that the benefits definitively outweigh the risks (and the unmentioned costs/harms)?

Further discrediting its recommendation on this, the ethics section (Pg. 759) 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.

The highlighted statement is the ethical argument. This accurate statement contradicts the conclusion the AAP presents that the potential benefits definitively outweigh the risks it considered. It is more relevant in the context of what the individual being circumcised might value. How will he – rather than his parents – want the benefits, risks, and costs weighed against each other for his normal, healthy foreskin? That’s the ethical core that the AAP Task Force sidestepped. Its recommendation for proxy consent for non-therapeutic circumcision is indefensible.

Moving on to the Ethical Issues section (pp. 758-760):

As a general rule, minors in the United States are not considered competent to provide legally binding consent regarding their health care, and parents or guardians are empowered to make health care decisions on their behalf.9 In most situations, parents are granted wide latitude in terms of the decisions they make on behalf of their children, and the law has respected those decisions except where they are clearly contrary to the best interests of the child or place the child’s health, well-being, or life at significant risk of serious harm.10

Sure. But that doesn’t support non-therapeutic male child circumcision. Proxy consent for permanent, amputative surgery must require something approaching objective need. Legally, we already require this for non-therapeutic genital cutting on female minors, including that which is analogous to or less harmful than a typical male circumcision. The comparison to be made for non-therapeutic male circumcision is whether or not parents are given this same non-therapeutic, cultural latitude in cutting the genitals of their daughters. They are not, which demonstrates that it shouldn’t be about the parents but about the child.

(a) Except as provided in subsection (b), whoever knowingly circumcises, excises, or infibulates the whole or any part of the labia majora or labia minora or clitoris of another person who has not attained the age of 18 years …

Subsection (b) establishes that only therapeutic genital cutting is legal for female minors. Subsection (c) rejects all parental preferences, whether cultural or religious, for non-therapeutic genital cutting on their daughters. It’s improper for the AAP Task Force to treat non-therapeutic male child circumcision as if it’s just a health care decision. It’s unlike any other decision we allow. If nothing else, circumcision guarantees (i.e. “significant risk”) the child’s normal, healthy foreskin will be removed forever (i.e. “serious harm”). Do male minors ever become reasonable people who may disagree about the weighting of the benefits and risks?

Revisiting “reasonable people may disagree”:

Parents and physicians each have an ethical duty to the child to attempt to secure the child’s best interest and well-being.11 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 situation is further complicated by the fact that there are social, cultural, religious, and familial benefits and harms to be considered as well.12 It is reasonable to take these nonmedical benefits and harms for an individual into consideration when making a decision about circumcision.13

It is not reasonable. The individual who must live with the permanent consequences of the decision, if the decision is to circumcise, is not the person taking these non-medical benefits and harms into consideration. (Here, based on my earlier excerpt from this paragraph, benefits such as a reduced risk of heterosexually-acquired HIV should be evaluated as non-medical because they are a non-therapeutic justification for surgical intervention via proxy consent. Or remedy my rebuttal to “these medical benefits, non-medical benefits, and harms” if my precision focused on the lack of need irritates.)

In footnote 13, which is Diekema’s “ethics” perspective on Boldt v. Boldt, he concludes:

(3) Absent a significant medical indication, circumcision should not be performed on older children and adolescents in the face of dissent or less than enthusiastic assent.

This is important. Infants can’t consent, of course, but there is no reason that an inability to consent should be construed as a “yes” in favor of his parents’ preferences. Not even benefits that reasonable people may determine do not outweigh the risks (and costs). From the Ethical Issues section of the policy statement technical report:

Parents may wish to consider whether the benefits of the procedure can be attained in equal measure if the procedure is delayed until the child is of sufficient age to provide his own informed consent. These interests include the medical benefits; the cultural and religious implications of being circumcised; and the fact that the procedure has the least surgical risk and the greatest accumulated health benefits if performed during the newborn period. Newborn males who are not circumcised at birth are much less likely to elect circumcision in adolescence or early adulthood. Parents who are considering deferring circumcision should be explicitly informed that circumcision performed later in life has increased risks and costs. Furthermore, deferral of the procedure also requires longer healing time than if performed during the newborn period and requires sexual abstinence during healing. Those who are already sexually active by the time they have the procedure lose some opportunities for the protective benefit against sexually transmitted infection (STI) acquisition, including HIV; moreover, there is the risk of acquiring an STI if the individual is sexually active during the healing process. (See the section entitled Sexually Transmitted Diseases, Including HIV.)

First, note that it references a section on STDs, including HIV. Condoms are a cheaper, ethical way of achieving the same benefits and in greater than equal measure. They’re also still necessary after circumcision to prevent STDs, including heterosexually-acquired HIV. Yet, the word condom appears¹ zero times in the body of the technical report. Why?

The same applies to the other benefits, or there are safe, effective, non-invasive treatments available. It’s also reasonable to infer that, since people may disagree based on their preferences for whether the benefits outweigh the risks, people may also differ on whether the cited gains from infant circumcision rather than voluntary, adult circumcision are worth the trade-offs of their foreskin and their choice. The “greatest accumulated health benefits” isn’t enough to justify circumcising the individual who will not want to be circumcised.

The most crucial sentence in that excerpt is the third. Males left with their normal genitals are less likely to elect (or need) circumcision. This is too often portrayed as something akin to weakness or cowardice in the autonomous male, for which parents can be the brave, responsible decision-maker. (e.g. Brian Morris et al.) That’s a bad framing device. Instead, this unwillingness (i.e. less likely) is the most powerful indicator that males left with their foreskin value something more than being circumcised. Even if that is merely a desire to avoid the (perceived) pain of the surgery, it is proof of their preference against being circumcised. It is not better to guarantee that pain by forcing it on them in infancy. The typical defense is that they won’t remember it, which is so ridiculous that it could justify any intervention. As AAP Task Force member and bioethicist Douglas Diekema said, “Not everyone would trade that foreskin for that medical benefit.” If the AAP had reflected that view in its recommendations, the revised policy statement could’ve been ethical.

For the remaining sentences, parents who are considering deferring circumcision should be explicitly informed that circumcision performed later in life has a very low likelihood of being necessary. Why leave this point out to focus only on one side of the equation if parents should be fully informed? It shouldn’t be included as an abused throwaway in a technical report most parents will never know exists.

In cases such as the decision to perform a circumcision in the newborn period (where there is reasonable disagreement about the balance between medical benefits and harms, where there are nonmedical benefits and harms that can result from a decision on whether to perform the procedure, and where the procedure is not essential to the child’s immediate well-being), the parents should determine what is in the best interest of the child. In the pluralistic society of the United States, where parents are afforded wide authority for determining what constitutes appropriate child-rearing and child welfare, it is legitimate for the parents to take into account their own cultural, religious, and ethnic traditions, in addition to medical factors, when making this choice.11

It is not legitimate. The Task Force’s own words demonstrate that it’s possible for the individual male to not value circumcision. He is in his parents’ care for 18 years. (Per Diekema’s recommendation, his parents may be able to choose non-therapeutic circumcision for only a few of those years.) He will then be an autonomous adult for what will likely be another 40 to 80 years. What will he believe is in his best interest about his normal body for that time period? If his parents circumcise him, he will never be autonomous on this question. (As his sister(s) will be by law, contra the absurd idea that parents should be afforded wide authority to determine what constitutes his best interest forever.)

This decision involves informed proxy consent, not informed consent. For this, non-therapeutic circumcision, there is no reasonable disagreement about the lack of need. What is in the child’s best interest is to not undergo unnecessary surgery for reasons he may not value. He can choose it later, or his parents can choose it should genuine medical need arise while he remains their responsibility. He can’t unchoose it once it’s imposed.

The technical report does not support the AAP’s recommendations because it contains omissions and contradictions. Both the technical report and the condensed versions are irresponsible documentd that will perpetuate the violation of the bodies and rights of newborn males. They should be retracted.

¹ It appears once in a footnote as part of the title of a source.


Flawed Circumcision Defense: Rabbi Shmuley Boteach

Posted: August 31st, 2012 | Author: | Filed under: "Voluntary", Ethics, FCD, FGM, Law, Parenting, Religion, Science | No Comments »

Rabbi Shmuley Boteach has an opinion piece in The Wall Street Journal titled, “Germany’s Circumcision Police”. It starts off well.

There was a head-spinning moment in Germany last week: News emerged that a rabbi had been criminally charged for performing his religious duties. Rabbi David Goldberg of northern Bavaria, who shepherds a 400-member community, is the first person to run afoul of a ruling by a Cologne judge earlier this year that criminalized circumcision, a basic religious rite.

There is some precedent outside of Germany for such a ruling. …

Even though we disagree on policy, agreeing on basic facts is always good. But his essay slowly falls off the path.

… In the United States, a San Francisco ballot initiative tried last year to make circumcision an offense punishable by a $1,000 fine and up to a year in prison; it failed to get enough votes. …

That’s not an accurate summary of what happened last year. A court ruled that the local ballot initiative conflicted with an existing state law and struck it from the ballot. It had nothing to do with getting enough votes.

… But the circumcision ban deserves universal scorn.

Does the German government really want to get into a public battle over whether they are better guardians of the health and welfare of Jewish (and Muslim) children than their parents?

As long as parents continue to circumcise their healthy sons, I hope so. Obvious physical harm for subjective non-therapeutic benefits is unacceptable without the individual’s consent. Protecting the rights of all citizens is a legitimate role of the state.

The Los Angeles Times recently cited a study predicting that as the number of circumcisions goes down in the U.S., the cost of health care will steadily climb. Eryn Brown reported that “If circumcision rates were to fall to 10% . . . lifetime health costs for all the babies born in a year would go up by $505 million. That works out to $313 in added costs for every circumcision that doesn’t happen.”

I’m not impressed by Rabbit Boteach endorsing the idea that a child’s normal body – and by extension, his rights – has a price beyond which we’ll justify non-therapeutic intervention to remove parts of it. But, more importantly, the key in that is not $313. It’s predicting. Aaron Tobian and his co-authors used a data model to make a guess. There are many factors involved. They are not constant. Cost, availability, and need could be quite different in two decades. For the potential benefits against sexually transmitted infections, circumcision can be chosen later. That would match the ethics of the studies that used adult volunteers. This study seeks to “prove” that a specific, non-urgent solution should be applied now, regardless of ethics.

Why? Because circumcision has been proven to be the second most effective means—after a condom—for stopping the transmission of HIV-AIDS, with the British Medical Journal reporting that circumcised men are eight times less likely to contract the infection.

He gets credit for mentioning condoms, which puts him ahead of the AAP. Still, condoms provide greater protection than circumcision, and remain necessary after circumcision. So, cost-wise, it’s condoms or condoms and circumcision. The former is cheaper and ethical. Infant circumcision is not ethical, including when potential benefits against STDs are cited.

While the Germans decry the barbarity of circumcision for men, they also overlook the benefit to women who are the men’s partners. Male circumcision reduces the risk of cervical cancer—caused by the human papillomavirus, which thrives under and on the foreskin—by at least 20%, according to an April 2002 article in the British Medical Journal.

They overlook the potential benefit to women? Do they? They can agree that (voluntary, adult) circumcision may confer reduced risk to female partners while also finding it unacceptable to impose circumcision on infant males (i.e. not “men”). Rabbi Boteach ignores the ethical foundation for the court’s ruling.

While some attempt to equate male circumcision with female clitoridectomy, the comparison is absurd. Female circumcision involves removing a woman’s ability to have pleasure during sexual relations. …

Not necessarily. Yet, in spite of that, it remains unethical. At some point, the human rights principle(s) involved must factor. Equal protection is a human rights principle.

… It is a barbarous act of mutilation that has no corollary to its male counterpart. …

This is also not true. Within what he wrote, it is, because he limited himself to clitoridectomy. The scope of illegal female genital cutting/mutilation is much broader than that, including any cutting that is anatomically analogous to (or less harmful than) male circumcision. That’s relevant.

… Judaism has always celebrated the sexual bond between husband and wife. Attempts to malign circumcision as a method of denying a man’s sexual pleasure are ignorant. …

Male circumcision controls male sexuality, with a long history as an attempt to limit sexual pleasure. It is still used to reduce pleasure for males.

… Judaism insists that sex be accompanied by exhilaration and enjoyment as a bonding experience that leads to sustained emotional connection.

If we ignore explicit statements in favor of circumcision as a way to diminish male sexual pleasure, Rabbi Boteach’s claim here is not mutually exclusive from reduced sexual pleasure. Intent does not guarantee outcome.

We Jews must be doing something right in the bedroom given the fact that, alone among the ancient peoples of the world, we are still here, despite countless attempts to make us a historical footnote.

This is evidence that male circumcision does not eliminate male reproductive ability. No one has claimed it does. His statement is a non-sequitor. The ability to reproduce is not proof that circumcision is acceptable or that it does not affect sexual pleasure or inflict harm.

Related: From the Cut Podcast, a debate between Rabbi Shmuley Boteach and Cut director Eliyahu Ungar-Sargon.