I Guessed What Phase Two Involves

Oh, what could this transition be?

The National Voluntary Medical Male Circumcision taskforce has rolled out the second phase of circumcision on regions with a high burden of HIV this time targeting over 1 million men.

The chairman of the Inter County Taskforce on Male Circumcision Dr Ojwang Lusi said the program is transitioning to the second phase of implementation that will run to July 2019.

We all guessed what this means.

The second phase will lower the circumcision age of boys to between 10-14 years.

I assume there’s a Phase Three – or an undocumented aspect of Phase Two – involving infant “men”. Predictably, it’s obvious why.

Lusi further noted that some challenges emerged in the first phase that they will strive to address as the second phase.

He said most of the men above 25 years declined to go for the exercise with limited number of women getting involved in the exercise with their husbands.

Men won’t volunteer, so child men get “volunteered”. As always with those who are unethical, because outcome matters instead of consent.

Joint Government Effort to Eradicate Consent

As always:

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

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

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

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

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

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

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

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

Put Health Before Politics

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

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

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

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

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

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

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

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

The Trauma of Small Numbers

At The Washington Post’s Wonkblog, Christopher Ingraham crunches through a few statistics about circumcision, with the headline writer concluding that “Americans truly are exceptional — at least when it comes to circumcision”. In the implied context of outlier for exceptional, yes, we are exceptional in our ability to ignore ethics and logic. Let’s not celebrate.

Most of the post is working through numbers. While relevant and informative, virtually everyone reading this will not be surprised by any of it. The encouraging aspect is in the access young people have to information.

Survey data indicate that we may see these declines continue. A YouGov survey conducted earlier this year found that young people were more skeptical about the practice than their elders: only 33 percent of 18-to-29 year-olds said that male children should be routinely circumcised, compared to 43 percent of 30-to-44 year-olds, 52 percent of 45-to-64 year-olds, and nearly two thirds of seniors.

This is why it’s critical to continue highlighting and objecting to garbage initiatives like the CDC’s recent draft proposal that focuses on infants. We’re convincing people that it’s time to stop circumcising.

The end of the post provides the information necessary to grasp the ethics.

… Overall, men who have been circumcised don’t appear to have many regrets about it: only 10 percent of circumcised men said they wished they hadn’t been circumcised, according to YouGov.

Since the number-crunching doesn’t quite get there, I want to open the perspective to what the numbers mean. At the time I’m writing this post, the U.S. Population Clock stands at 320,952,250 Americans. That means there are approximately 160,476,125 American males. Given that infant circumcision rate spent decades in the 90% range but is now lower, I’ll estimate that 75% of American males were¹ circumcised. That estimate results in 120,357,093 circumcised American males. Applying the survey’s 10%, I wish to restate Mr. Ingraham’s conclusion to consider whether his analysis should survive further number-crunching.

Overall, men who have been circumcised don’t appear to have many regrets about it: only 12,035,709 circumcised men said they wished they hadn’t been circumcised.

We mistakenly think about circumcision in terms of statistics and probabilities. That hides the violation involved, and allows society to believe we’re doing something good. But there is an individual at the tip of every scalpel. I think one is an exceptional, too-large number in the context of a male regretting non-therapeutic circumcision without his consent. However, it’s easy to imagine that ten percent is a small, inconsequential number. It is neither small nor inconsequential. We must realize that twelve million males² is a large, inexcusable number.

¹ Some might argue I should say are circumcised. I criticize the act of circumcising healthy males without their consent, not the state of being circumcised, however the male got to that point. It’s the ethics against circumcision, which includes the ethics against body shaming. I support any male’s decision to be content being circumcised.

² It’s worth remembering that some number of the content 90% would be content with their foreskin. It’s a mistake in the ethical evaluation to conclude that contentment by itself is a justification. That is dealing only with what is seen. Do not ignore what is unseen.

Revising Tactics

This excellent post on activism by Freddie deBoer captures what I’ve been thinking lately. The context is different, and I largely disagree with his politics, but the larger theme remains activism and convincing people of ideas. If you only have time to read Mr. deBoer’s post or what’s below, click that link.

I’ve been frustrated about the direction of activism for genital integrity rights for a longer time than I’m willing to accept. I’m not going anywhere. I haven’t changed my mind. But it’s difficult to expend the effort when so many are fighting those who agree on the goal and demonizing those who we need to convince. Maybe there’s a cause where a punch in the nose is the right activism. This isn’t it. Doing so only makes the process harder and further pushes out the day we achieve full protection for all children, male, female, or intersex.

I remember many political fights over the last decade-plus that I was sure would turn out a specific way. The most recent example is the general election in the United Kingdom last week. I was convinced Labour were going to win. “Go Labour” was all I saw on Twitter. The Rise of Ed Milliband was everywhere in my news feeds. And then the election happened. David Cameron remains Prime Minister, but with an actual majority instead of a coalition government. The exact opposite of the expected result occurred.

British Politics Twitter melted down from the moment the first exit poll leaked. “How could this be? Impossible! We’re doomed!” And so on. I reacted this way in years past, and I felt justified in doing so. I’m right, after all. Except when this happens enough times, it’s wise to step back to figure out why expectation and result don’t match. We need to examine that chasm for genital integrity rights.

I believe the explanation for this experience is the same for politics and genital integrity. The Internet is not society. The Internet is a specific, motivated subset of society. It will change the world, probably. But this change will occur only if we realize that most of the people we need to convince don’t care about our obvious intellectual win in a long-running feud with oppositional trolls.

It isn’t that a large percentage of society is being obstinate, refusing to change. For most people the issues important to activists aren’t merely unimportant. They aren’t real. How many times have we heard, “I don’t know any men who miss their foreskins/regret being circumcised”? The answer is always, accurately, “Yes, you do. You don’t know who they are because it isn’t safe to say such a thing in most company.” Consider the immediate reaction in the UK election: “Why were Tories so afraid to tell pre-election pollsters that they’re conservatives?” It’s more reasonable to recognize that some people will not tell another their truth if they believe it will be dismissed or ridiculed.

That’s the crux. People aren’t evil. They’re unaware. It’s ignorance in the purest definitional reality. Perhaps there is a better way for them. We can show them. Will we show them?

With politics, we all believe that our views are correct. Maybe. With genital integrity, the truth is clear rather than subjective. Society should already be where we are on this issue. Of course. But it would be foolish to use that to inform our activism. We must educate. Antagonizing only keeps us out of the experience of those we need to convince. As I’m sure I’ve written before, would we rather be right or victorious?

It would be wonderful if we could explain ourselves to a sufficient number of judges and legislators. Boom, everything changes. That isn’t how change happens. Courts and legislatures lag society. Justice derives from those who refuse to participate in injustice any longer, not those who would command us not to participate. This is true even though providing legal protection for the inherent right to genital integrity to all citizens is the only ethical stance. The burden of proof shouldn’t be on us. The burden of proof is on us.

Where do we go from here? I wish I had the magic words that would fix this. However, if you read Mr. deBoer’s post, magic words are the opposite of what we need. We have too many magic words now. Cutter. Circumfetishist. Rape. Sexual crime. And so on, even to mutilation in many contexts. Using these words signals to a preferred segment of activists that only we understand how truly awful circumcision is. Perhaps. And it feels so good, right, so it doesn’t matter what the cutters and circumfetishists think, except what the people called cutters and circumfetishits think is all that matters. They have all the power to stop circumcision. We need to stop aiming to convince those who are already convinced.

How do we educate the people who need to be convinced?

The stink of uneaten side orders

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

**********

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

Unsettling the settled

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

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

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

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

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

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

Thinking out loud: thoughts on civility

When I complain about certain behaviors within our community, I’ve thought about them. I’ve witnessed them. I’ve seen fence-sitters become opponents. I’m working to figure out what is effective at getting our message across.

I also believe in decency and treating people with respect. I find it exhausting when people support circumcision, or merely parental choice, based on incomplete and/or wrong reasons. But outside of a few examples we can all immediately name, most people who accept such reasons are doing what they can. In the best sense, they don’t know yet. I don’t accept that as a sufficient defense, but we’re not going to achieve anything good by ignoring reality. Our job is to get people to full understanding, not to demolish them for not being there yet.

In essence what I write on this is often me thinking out loud. My experience shows me lessons I believe are universal. I may not be expressing my ideas clearly enough, or acknowledging that I know the line is grey. I’m trying to find that line, if it exists. More than anything I want us to succeed. But I haven’t forgotten this possibility on what effective civil discourse means: I may be wrong.

Activism is always about marketing

I like this post by Jonathan Friedman:

Friday, February 6 is International Day of Zero Tolerance for Female Genital Mutilation (FGM). There is a lot of positive momentum in the UK and around the world for education and prosecuting those who practice or aid FGM. This is a day for us to learn more about FGM, to listen to the victims and to learn how FGM is being eradicated. Many of us know very little about it and have never even met victims of FGM.

That’s correct. It’s too easy to forget that children are violated, not just boys, because of what is most familiar. It’s also critical to remember this reality:

Unfortunately, there’s also a great deal of sexism within the discourses on FGM, especially coming from cultures practicing male genital mutilation (MGM). Great care is taken to state that MGM and FGM aren’t comparable, while intersex genital mutilation (IGM) is virtually ignored. MGM has recognized health benefits, FGM does not, they point out. MGM is a religious requirement, FGM is a cultural practice. And so on.
…

Many women’s organizations recognize MGM for what it is and speak out. On December 12, 2012, I attended my first Bloodstained Men & Their Friends demonstration in Berlin, Germany, the day the German Parliament passed a new law enshrining MGM as a religious right. The event was co-organized by Terre Des Femme, a women’s rights organization. I can’t express how comforted I felt getting up there on stage in a bloodstained suit with a group that included a woman.

People are complicated. I trust that anyone opposed to FGM is – or can be – receptive to the truth that boys have the same rights as girls. We should challenge mistaken beliefs where possible. But we can’t make enemies of potential allies because it feels good to launch these wide, careless attacks. Everyone involved is justifiably angry to some extent. Some are angry, and others are more angry. It’s natural. We can’t allow that anger to become so righteous that we lose control. Don’t be an accelerant:

So to them I say: don’t be an accelerant. Be a passionate advocate when necessary. Speak truth to power when you feel it’s right. But train your powerful tools of criticism of others on yourselves, and be ruthless when it comes to your own good intentions. Ask yourself: when I intensify this conflict, when I beat my chest and declare someone evil, when I throw fuel on the fire, am I really helping the people of color and women I claim to speak for? When I go for the jugular again and again, am I actually helping to solve injustice? Is this kind of engagement from me an instrument of political progress? If not, why am I doing it? How am I contributing to this cause?

The context is different, but the same. It never helps protect children when someone spews hatred at a group of people united only by the attacker’s presumption of the group’s hatred of boys. Pick a group targeted for vitriol, whether it’s women as in the tweet linked above, or Jews, or doctors, or any group, really. When did smearing someone achieve a single helpful thing? Lazy accusations of misandry don’t help. How many times do any of us need to see images from issue two of Foreskin Man in news stories and blog posts to understand how damaging that vileness is? You think you’re making the point that circumcision is awful and how dare you not understand that circumcision is awful. You’re making the point that you’re unhinged and scary and best ignored.

Back to Mr. Friedman’s post, in this paragraph he states exactly what activism should be:

When space is created for talking about FGM, we need to respect the intentionality of that space. When that space is used to defend MGM or IGM, we must raise our voices as appropriately as possible. We have been accused of minimizing FGM by comparing it to MGM and taking resources away from FGM, as if we’re all in competition. Whether or not these allegations are true, people perceive these as being true (on the whole I think they’re false, but I can’t speak for everyone).

It’s correct for discussions of FGM. The concepts of appropriateness and respect are broadly applicable. That willingness to consider others and to understand that we need to explain our position will achieve more than “Shut up” ever could. Do we want to feel superior or do we want to protect children?