Another Reminder

Posted: April 15th, 2014 | Author: | Filed under: "Voluntary", Public Health | No Comments »

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

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

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

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

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

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


The Equation Is Unnecessary Genital Cutting Minus Consent

Posted: March 23rd, 2014 | Author: | Filed under: "Voluntary", Control, Ethics, FCD, FGM, Logic, Media Marketing, Parenting, Politics | No Comments »

Many have heaped scorn on Mary Elizabeth Williams’ Salon piece that criticized Alan Cumming for calling male circumcision genital mutilation and comparing it to female genital mutilation. This scorn is deserved.

Alan Cumming wants to tell you about his penis. He wants it to be a shining example to the world. In a candid interview with Drew Grant this week in the New York Observer, the 49-year-old Scottish actor reveals his strong opinions on “Girls,” naughty cellphone pictures, and, most controversially, circumcision. Or as he puts it, “genital mutilation.”

“There’s a double-standard, which is that we condemn the people who cut off girls’ clitorises, but when it happens to boys,” Cumming says. “I mean, it is the most sensitive part of their bodies, it has loads of nerve endings, and it can go horribly wrong. I’m speaking out against it … I’m just so suspicious of the medical industry, which just flings pills at people to ensure everyone is reliant on things. ‘Here are some pills, Mommy. Take them, and we’ll take your baby away and hack its thing off, and then we’ll bill you for that too.’”

I don’t share Mr. Cumming’s view of the medical industry. Its complicity strikes me as cultural inertia and cowardice. My experience suggests that profit-driven focus on circumcision is limited, although it motivates some. But that’s a distraction. The key is that he is correct about the comparison.

Circumcision of a healthy male minor is mutilation of that male’s genitals. To be valid, it must involve his consent prior to the surgery, not assumed to be later granted retroactively. This is the standard inherent in 18 USCS § 116, which criminalizes all non-therapeutic genital cutting on female minors without regard for parental justifications or potential benefits. The difference we imagine is an accident in the history of Western child genital cutting.

Later in the essay:

… And earlier this week, protesters threatened to disrupt Bill and Melinda Gates’ TED Vancouver talk because of their organization’s efforts to increase the practice in Africa as a means of “limiting the spread of HIV in the parts of Sub-Saharan Africa.”

There is good reason to find the work of the Gates Foundation repugnant, as it pertains to male circumcision. It speaks in the euphemism of voluntary medical male circumcision, when it also means infant circumcision. This is unethical because it violates the principles of bodily integrity and consent. And this study, commissioned and funded by the Gates Foundation, hardly provides reassurance when examining the context of WHO and UNAIDS, who think violating this human right of male children can be legitimized through question begging. Mental gymnastics like that are not admirable.

Cumming’s equation of circumcision with female genital mutilation is an insultingly inaccurate one — boys are not circumcised as a ritualized means of suppressing their future sexual enjoyment,

Although it’s easy to find similar defenses of male circumcision, ritual or not, this implies that the critical issue is intent rather than outcome. Female genital mutilation, in all its forms, is wrong because the female is mutilated, not because she is mutilated for “bad” reasons. Some reasons given are the same as those for male circumcision. And not all females who were mutilated reject or condemn it. Yet all reasons for surgically altering the healthy genitals of a female minor are still bad. This focuses on the principles and facts involved, not our feelings.

Notice, too, how often erroneous claims like “[t]here is no evidence whatsoever to support the notion that it affects function, sensation or satisfaction” are made about male circumcision, as it’s made with that quote from Williams’ link to reader comments on an article. The statement is wrong on its face because circumcision changes the function. If you change the form, you change the function. The function of the penis, including its structure, should not be lazily defined as “to have sex” or something similarly ridiculous. The foreskin is normal anatomy with functions for the penis and belongs to its owner.

The quote is disputable on sensation, considering the (anecdotal) arguments in favor of male circumcision stating that males can “last longer“. Consider the heads I win/tails you lose efforts of Brian Morris here, as all outcomes are assumed to be favorable to overall satisfaction, even when the studies cited do not involve anything near 100% on the subjective evaluation of satisfaction.

nor does a clean male circumcision compare with the often crude, blunt and unsanitary practice of female genital mutilation.

Those qualifiers obfuscate. What about clean female genital cutting compared with crude, blunt, and unsanitary male circumcision? A sterile surgical environment does not grant legitimacy to a rights violation. Again, the act is what matters. There are degrees of harm possible, but the inevitability of harm requires first priority, whatever the degree.

The World Health Organization calls FGM “a violation of the human rights of girls and women” with consequences that include “severe pain, shock, hemorrhage (bleeding), tetanus or sepsis (bacterial infection), urine retention, open sores in the genital region and injury to nearby genital tissue,” while it in contrast notes, “There is compelling evidence that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%.”

WHO also explains that female genital mutilation “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.” There is no unethical caveat for “but if we find some benefits to female health, or even male health, we’d have to weigh mutilating injury against potential benefits.” That unethical caveat is always applied to male genital mutilation, as Williams does here. An adult male volunteering is not the same as an infant male being volunteered. Consent is the issue, not how horrible female genital mutilation usually is or how innocuous and/or beneficial male circumcision appears to be. Non-therapeutic genital cutting on a healthy individual who does not consent is unethical. It involves harm. Gender is irrelevant to the principle.

One can argue, quite persuasively, about whether the practice of circumcision still has validity here in the West, especially among those who don’t have a religious directive. What’s needed, however, is education and enlightenment, so families can make the healthiest choices for their children. …

I reject the premise. This is a not a decision parents should be allowed to make for their children. The argument that parents may decide this for their healthy children requires this decision to be a parental right. If it’s a parental right, then the prohibition of non-therapeutic genital cutting on daughters is indefensible. The basis for thinking about genital cutting can’t be girls and the parents of boys. That’s absurd.

… It’s not helpful to make far-fetched comparisons, and it certainly isn’t constructive to imply that men and boys who are circumcised are somehow damaged, “mutilated” goods. That’s a shaming technique that serves no one, one that turns having a foreskin into a bragging point. …

Why are we only worried about shaming men and boys by using the term “mutilation”? Isn’t there the possibility or likelihood that women and girls will feel shamed if we describe their genitals as mutilated? Are the psyches of females more able to handle facts?

There is a difference in stating a fact and demanding a value judgment from that fact. The bodies of males who were circumcised as children were mutilated. Their rights were violated. Circumcised males are not obligated to think this is bad or shameful. The obligation (for everyone) rests in understanding that it is unacceptable to perpetuate this violation on their children or to permit its continued practice in society.

Or to put it in terms of individual autonomy, circumcision mutilated me through the deprivation of an essential¹ part of my body. Where I had a normal human foreskin, I now have only scars. My penis is mutilated. No one gets to reject that fact for me. But I do not feel shame. This sense that males might feel shame is what encourages parents to circumcise their sons for conformity. We have to stop being afraid of shame. We’ll achieve that only when we are no longer afraid to state that shame belongs with those who circumcise, not those who are circumcised.

… And it’s an unfair judgment coming from a man who admits, “I myself don’t have kids. I just have managers, assistants, agents and publicists.”

I feel second-hand embarrassment, so that at least someone feels what her statement deserves.

¹ Quibble with essential as something other than an obvious stand-in for normal, and I’ll roll my eyes and ask if normal parts of female genitalia are essential.


Flawed Circumcision Defense: Yair Rosenberg, Part 3

Posted: December 30th, 2013 | Author: | Filed under: "Voluntary", Ethics, FCD, Logic, Media Marketing | No Comments »

It won’t come as a surprise to read that I don’t think much of Yair Rosenberg’s lazy approach to analyzing non-therapeutic infant male circumcision. Add another example. This time he’s misreporting the findings of another meta-analysis by Brian Morris. Mr. Rosenberg quotes from a Daily Mail article that amounts to little more than a press release.

But first his introduction:

Across Europe, pushes to ban circumcision have rested on its supposedly deleterious effects on a child’s body, and lack of demonstrable benefits. Anne Lindboe, Sweden’s child welfare adviser, has gone so far as to label the practice “violence against children,” claiming that parents who perform it do so out of “ignorance.” She and her counterparts in Denmark and Finland have classified child circumcision as a “human rights violation” and called for it to be criminalized. A German court similarly banned the procedure on the grounds that it caused “bodily harm.” The only problem with these stances? They completely contradict everything science has found about circumcision’s impact on children’s health.

Findings of potential benefits from voluntary, adult male circumcision do not contradict the ethical, rights-based position against non-therapeutic infant male circumcision. Proxy consent is not the same as the consent given by adult volunteers to this permanent, irreversible surgery. Circumcising healthy minors violates their rights to bodily autonomy and integrity, just as any other permanent, non-therapeutic intervention is a violation. It’s the same principle that applies to even the tiniest, less-invasive-than-male-circumcision cut on a female minor’s genitals, which we’ve rightly criminalized. Potential benefits and human rights violation are not mutually exclusive. The presence of potential benefits does not eliminate the fatal ethical flaw. Nor does deciding that circumcision diminishing sexual function, sensitivity, or satisfaction is a “myth”, as Mr. Rosenberg claims of the new meta-analysis by Prof. Morris and Dr. John Krieger.

With that misguided frame, Mr. Rosenberg presents the study:

“The highest-quality studies suggest that medical male circumcision has no adverse effect on sexual function, sensitivity, sexual sensation, or satisfaction,” Professor Brian Morris told The Daily Mail. Morris and his co-author looked at 36 studies covering 40,473 men, half circumcised and half not. They ranked each in terms of scientific rigor and quality, according to accepted official guidelines. And they found that circumcision “had no overall adverse effect on penile sensitivity, sexual arousal, sexual sensation, erectile function, premature ejaculation, duration of intercourse, orgasm difficulties, sexual satisfaction, pleasure, or pain during penetration.” Indeed, after 24 months, 99.9 percent of men were satisfied with their circumcisions–and 72 percent said sensitivity had increased.

There’s a lot to unpack there. The largest point is that Mr. Rosenberg clearly didn’t read the 12 page paper because he regurgitates the results in the digestible (i.e. misleading) package given in the news article. Reading it might reduce his confirmation bias. There are enough obvious limitations, as well:

While the review considered a large body of evidence, there are some factors that may be influencing the findings.

For example, many studies were surveys, and the recruitment process for them is not described. It could be the case that men who have a satisfying sex life may be more willing to participate and answer questions on sexual performance and satisfaction that those who aren’t.

Also, most of the responses in the study are subjective, and what one person considers to be a sexual problem or sexual satisfaction, another might not. There may also be differences in the culture and ethnicity of the participants of certain studies, meaning that their findings cannot be so easily transferred elsewhere.

Beyond that, focus on the conclusion from the study. They state that their analysis suggests this conclusion. Suggests is not a synonym for proves. Yet, even though the Daily Mail article doesn’t use the word in quoting Morris, Mr. Rosenberg states:

Morris told The Daily Mail that he saw his study disproving circumcision’s adverse effects as complementary to those showing its benefits. …

He repeatedly misses the critical issue of consent versus force. In a previous article Mr. Rosenberg summarized a finding that “[i]t would have been unethical to continue without offering circumcision” to the remaining intact volunteers in a study with a simple statement that it would be “[u]nethical not to circumcise the men.” It appears that Mr. Rosenberg is not a reliable filter for news pertaining to circumcision.

There are obvious problems in the current meta-analysis. I will accept their methodology and reasoning as presented, which lead to their “suggests” conclusion. Assuming it is accurate, so what? The findings were not 100%. Of course, 99.9% is presented as essentially the same thing, which is even better than the result we’d expect from a dictator’s latest popular election. From the Krieger et al. Adult Male Circumcision study in Kenya [15]¹, 8.9% of circumcised men identified their penile sexual sensation as something other than “increased” or “the same” 24 months after circumcision. It’s ridiculous to pretend that these men don’t matter and that their experience should be ignored to allow a perceived universal defense for circumcising male minors.

Mr. Rosenberg concludes:

Yet the findings of science have done little thus far to deter Europeans politicians and health officials from seeking to criminalize circumcision, and labeling those who practice it “ignorant” and “barbaric.” It remains to be seen if this study will alter their course.

A utilitarian defense for violating human rights is ineffectual because the defense relies on using only a preferred subset of factors to reach a conclusion. “It’s mine” is a sufficient reason for a male to want his foreskin. He owns his foreskin as much as he owns any other part of his anatomy. Potential benefits valued by his parents are irrelevant while his body is healthy. Proxy consent for this non-therapeutic intervention is invalid because the net benefit or harm is subjective to the individual himself.

This is obvious if considering the question Morris and Krieger asked. Does male circumcision affect sexual function, sensitivity or satisfaction? In order, yes, maybe, and maybe. The findings suggest as much if we look at the participants in the included studies as individuals with their own unique tastes and preferences rather than as statistics. The paper’s focus is sex as a measurable number, which is an idiotic way to reach a conclusion about a subjective topic like human sexuality.

For sexual function, the foreskin is removed. That changes function. Maybe that’s “good”, maybe it’s “bad”. Each person must decide before circumcision what he thinks he wants. What his parents prefer is meaningless.

As for sensitivity, the results are equivocal. I’m willing to accept the negative findings as lower-quality studies for this purpose. But in a study Morris and Krieger rate as 2++, Payne et al [12], this:

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

Yet, for Morris and Krieger, this is support for their “suggests” conclusion because:

… More circumcised participants reported an increase in their level of sexual arousal, while more uncircumcised men reported being unaffected by the erotic stimulus. …

They want to believe, so they believe. That’s the only way I can reconcile the source study with their analysis.

In certain aspects sensitivity is quantifiable, but there is a an element of experience to human sexuality that a generalized “yes” or “no” here dismisses. That same element of experience, but without the ability to quantify in a utilitarian summary, exists in personal evaluations of satisfaction. This is why I don’t state that someone is wrong for preferring circumcision or believing it improves their experience of sex or life, in general. But that is also why it’s wrong for Morris, Krieger, Rosenberg, or anyone else to support parental choice (i.e. proxy consent) for non-therapeutic circumcision. Declaring one’s own preference as a truth applicable to someone else – without concern for the individual’s preference for himself – is the critical mistake inseparable from their argument.

One final point: It’s important to read the abstract and the study rather than just the abstract, even as a layman. Doing so reveals a lot of nuance, as the AAP’s revised position statement in 2012 so embarrassingly showed. It avoids the “It’s official!” conclusion too many (like Mr. Rosenberg here) want to staple to the evolving science involved in circumcision. The Payne [12] study is another example of the importance of this maxim, as are the remaining studies reviewed by Morris and Krieger, probably.

¹ Bracketed numbers correspond to the same-numbered footnote in the Morris/Krieger review.


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.


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.


Know the Facts That Discredit Infant Circumcision

Posted: June 23rd, 2013 | Author: | Filed under: "Voluntary", Control, Public Health | No Comments »

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

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

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

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

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

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

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

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

For example:

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

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

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

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

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

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

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


Genital Mutilation Is One Cause

Posted: March 17th, 2013 | Author: | Filed under: "Voluntary", Ethics, FGM | 1 Comment »

Owen at Oggy Bloggy Ogwr posted a fascinating discussion on International Women’s Day – Life, Ethics & Independence III – Circumcision. He’s thorough and makes a strong case, summarized with this:

I think the point I’m trying to make here is that perceived injustices that might be deemed “the same cause” for both sexes might not be similar at all. It’s issues like this that mean we have/need an International Women’s Day in the first place.

There are millions of women who currently have to endure some of the worst abuses humankind can throw at them for simply being born the “wrong gender”, and who don’t have much of a voice – except on days like today.

His post is strong because he addresses the issues involved rather than defending International Women’s Day with the rhetorical equivalent of “Shut up, men”. I disagree with very few of his points in the post. However, those few lead me to disagree with his defense of his conclusion, while accepting his conclusion that there is value in addressing the injustices women and girls still face and doing so on their own. Basically, his second paragraph stands without the incorrect qualification presented in the first.

My primary disagreement is here:

Is there a double standard here?

Uh….no.

If female circumcision only ever involved removing the clitoral hood – the female equivalent of a foreskin – and was still deemed “genital mutilation” then you would have a point. I doubt you can compare this with women making an informed and conscious choice to have various “body modifications” either.

The UK and US anti-FGM acts prohibit all non-therapeutic female genital cutting, including that which is analogous or less damaging than male circumcision. They prohibit “procedures that intentionally alter or injure female genital organs for non-medical reasons.” The WHO fact sheet on FGM defines it as “removing and damaging healthy and normal female genital tissue, and interferes with the natural functions of girls’ and women’s bodies.” All non-therapeutic cutting on a female without her consent is (rightly) considered mutilation.

Male circumcision fits within both descriptions above, as well as the definition of mutilation. There is no valid reason to distinguish non-therapeutic genital cutting on a non-consenting individual as mutilation or somehow not. The lack of consent to any level of permanent, non-therapeutic surgical harm is the critical issue in identifying genital mutilation. Male circumcision or hoodectomy or any other non-therapeutic cutting is ethically acceptable only when voluntarily chosen by the individual receiving it. Proxy consent is still lack of consent.

I recognize the often great difference in severity from what is typically done to males and females. That matters, and should inform penalties, whether criminal or civil. This difference should not inform legality. (The challenge of enforceability can’t be ignored, of course, but that’s separate from what “should be”.) As I’ve said before, a punch to the face is still battery even though a knife to the gut generally causes more damage.

To be fair, Owen made it clear that he understands the problem inherent in male circumcision. He disagrees with imposing it on children. I am not saying anyone needs to fight male circumcision in their fight against FGM, even though they are the same cause in principle. My point is that FGM is bad enough on its own that making that case doesn’t need a separation of male circumcision from mutilation. This is also true because separating male circumcision from mutilation is counter-factual.

(Conversely, the case against male circumcision can be made without a comparison to FGM.)


Ghana Encourages Unethical Infant Circumcision

Posted: February 12th, 2013 | Author: | Filed under: "Voluntary", Ethics, Public Health | 1 Comment »

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

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

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


Dr Limakatso Lebina’s Ridiculous Circumcision Euphemism

Posted: February 11th, 2013 | Author: | Filed under: "Voluntary", HIV, Media Marketing, Public Health | 3 Comments »

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

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

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

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

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

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

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

This, though, is absurd and offensive:

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

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

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

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


America Participates in Forced Circumcision

Posted: November 2nd, 2012 | Author: | Filed under: "Voluntary", Control, Ethics, Religion | No Comments »

An article from the American Association of Clinical Urologists in Urology Times offers a frustrating introduction to the current circumcision controversy:

Legislators, researchers, imams, and rabbis argue whether male circumcision decreases certain diseases, whether a child can or should give consent, or whether religious freedom should trump all of this. Public policy discussions that are taking place throughout the Western world—specifically, the U.S.—have implications for urologists.

Americans are mostly insulated from horror stories around the globe, such as in Indonesia, where religious extremists who practice forced circumcision on men, children, and even pregnant women in attempts at forced religious conversion; or in South Africa, where certain cultures allow for the forced circumcision of boys deemed to be “past the age of initiation.” Female circumcision is now called “female genital mutilation” and is illegal in most of the Western world.

All non-therapeutic genital cutting on a non-consenting individual is “forced circumcision”. That includes every circumcision of a healthy American boy. The issue at hand is force. (e.g. force is force) All the comforting justifications offered in the West for a nonsensical exemption to basic human rights and medical ethics for male child circumcision do not change the violation of forcing this non-therapeutic surgery on those who cannot consent. The foreskin is a normal body part, not an irrelevant “extra bit of skin” that may be removed from a minor (male only, of course) because it might cause some problem some day, no matter how likely, preventable, or treatable. (Worse: the other more bizarre reasons we accept from parents for this surgery.)

The article’s conclusion is frustrating, as well. I understand not wanting to take a stance on which side is right. However, that’s the critical question, especially if more non-therapeutic child circumcisions will be pushed to doctors as law and culture changes. The focus should not be on the possibility that these changes could increase urologists’ liability premiums. It would do that because more complications would occur in doctor-performed circumcisions. That’s simple numbers. But those complications don’t have to happen. When a requested circumcision is not medically indicated and the patient can’t consent, the critical question of which side is right must be addressed. There is an ethical answer. As the article points out, “[c]omplications stemming from circumcision may have lifelong implications for the individual at the other end of the knife, no matter their age.” What does the child want in the absence of need? When he can’t consent, no one should participate in circumcising him.