America Participates in Forced Circumcision

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.

Argument from Ignorance and/or Hatred

In a letter to the editor of the Standard-Examiner in Ogden, Utah, a reader attempts to make a point about Sharia Law. I’m not going to wade into the political aspect of this. But the reader makes an informative error. He writes:

When girls reach age 12 to 14 they are held down, naked, by usually their mothers or as many men that it takes to hold them down, as they cut their clitoris off. They say this helps to control them. Then the girl’s legs are wrapped together for 40 days so the wound can heal.

I could quibble, but this more or less sets up the issue. FGM is evil. But the reader loses his narrative in the next paragraph. He gets basic facts wrong that contribute to a mistaken distinction that doesn’t exist within the principles he aims to establish. (emphasis added)

They tell the little girls that this will make it more pleasurable for their husband when they get married while being denied any sexual pleasure themselves. This mutilation of the genitals makes it painful to have sex and extremely painful to bare children. Everyone knows that they have to be covered up head to toe and escorted by a male wherever they go, but I wonder if the American people know that it is OK to beat their wives by hand or by stick as needed. Or that they are forced to perform oral sex with their husbands, who have not been circumcised so the penis stinks due to the buildup of urine. If the woman complains the husband cuts off her nose.

The principles he implies are the basics. Females possess the rights to their bodily integrity and autonomy. They should be free from unnecessary harm without their consent. Cutting their healthy genitals violates them. It is bodily harm. They are mutilated.

The problem here is that the same rights exist for males. Non-therapeutic genital cutting on a non-consenting individual, not just the genital mutilation of girls, violates the principles involved, regardless of the extent. The husbands of these women are almost certainly circumcised. Their genitals are not cut to the extent that their wives’ genitals are cut. They are cut, though. I’m not aware of any cultures that cut females that don’t also cut males. (Please correct me if I’m wrong.) In Egypt male circumcision is practiced as a part of Islam.

The reader’s comment that the husbands are not circumcised would be bad enough on its own because it’s inaccurate. The additional “so the penis stinks due to the buildup of urine” is projection. It strives to distinguish forms of non-therapeutic genital cutting with an ignorant dismissal of basic hygiene. It seeks to reiterate a validity and desirability for male circumcision, without regard for the male’s preference. The issue the reader raises but fails to crystallize is the use of force.

Forcing genital mutilation on girls is wrong. Forcing wives to have any form of sex is wrong. That extends to males, as well, if the desire to protect females is to carry complete moral weight. Any system – whether political, cultural, or religious – that permits or encourages the use of force by one citizen against another citizen for any reason other than self-defense is illegitimate. The reader’s core point is correct. He should apply it as a universal to all people, not selectively as an instrument endorsing his own cultural relativism. (He is not unique in this, of course. Commonality doesn’t justify it.)

Zimbabwe Commits to Unethical Infant Circumcision

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

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

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

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

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

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

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

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

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

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

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

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

Joya Banerjee Misunderstands Opposition to Circumcision 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’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.

AAP Circumcision Policy – Flawed Ethics

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.

The New Marketing in Action

Last month I showed that the marketing for circumcision had changed again to eliminate any remaining concern for either voluntary or adult. Voluntary, adult male circumcision had been rebranded down to “safe male circumcision”. Here is the inevitable goal being realized in Botswana. Babies to be circumcised:

As a long term plan to fight the HIV/AIDS spread the Ministry of Health will now introduce a Safe Male Circumcision (SMC) programme targeted at male babies and infants. In the past few years the government has been preaching SMC to males who are in sexually active ages.

“Towards the end of this year we want to enrol babies in the SMC programme and parents will be sensitised on the programme and its procedures. We have realised that targeting sexually active aged men and youth is not enough; we should have a long term vision for our strategies; targeting babies will result in the country having less people at risk of being infected with the virus in the next 15 to 20 years,” [Conrad Ntsuape, the National SMC Coordinator in the Ministry of Health] said.

When public health officials say voluntary or adult, they never mean voluntary or adult. They are “targeting” and “enrolling” infant males. It’s propaganda.

Also notice the fallacy that circumcising infants will result in fewer people at risk of being infected with HIV in the next 15 to 20 years. That is inaccurate, and a warning sign that they do not understand what they are doing. Circumcising infants will (allegedly) result in more males with a reduced risk of becoming HIV infected during vaginal intercourse with an HIV-positive female. Each male still retains a risk of infection, and without other (more effective) changes, including consistent condom use, men – and their partners – will still become infected. Spreading this incorrect understanding is an effective way to continue the spread of HIV.

Relevant to this problem with marketing:

Media were singled out as not playing a visible role in relaying the message on SMC. Beauty Gakale, the SMC Regional Coordinator said SMC should be given wide coverage to avoid confusion and misconceptions about it in the public. “Media, especially private media have been less active in relaying the SMC message and it is high time they played a role in this. We are also urging political leaders to play their role by encouraging men to undergo the SMC. ”

Public officials should worry about their own mistakes before demanding that media assist them in pushing propaganda. For example:

Asked why the advantages of the SMC are communicated to the public while the disadvantages are hardly discussed, Dr. [Adrienne] Musiige said SMC is like any other surgery and can be susceptible to infection if not well managed.

That didn’t answer the question.

Evaluating the Genital Cutting Analogy

Catarina Dutilh Novaes has an excellent post on the comparison between male and female genital cutting.

 A heated discussion ensued from my post on circumcision last week, which in turn was essentially a plug to a thought-provoking post by Brian D. Earp at the Oxford Practical Ethics blog. The controversial point was whether circumcision is or is not to be compared to female genital cutting.

I’ve learned a lot from the different perspectives presented during the discussion; among other things, I’ve learned the terms ‘genital alteration’ and ‘genital cutting’, which now seem to me to be more adequate than either ‘circumcision’ or ‘genital mutilation’ to formulate the issue in a non-question-begging way (as argued here). And yet, I am now even more convinced that the analogy between male genital alteration and female genital alteration is a legitimate one – which (and let me say this again!) does not mean that there are no crucial differences to be kept in mind. That’s what an analogy is, after all.

I agree with this, and the bulk of the post. I recommend it with only a minor quibble and an additional piece of modern evidence.

My quibble:

It is well known that female genital cutting is practiced with different levels of severity, going from pricking and piercing to infibulation. …

I do not believe this is well known beyond academic knowledge. In my experience the average person hearing this comparison believes that female genital cutting is always a) the most severe form, b) performed to eliminate all sexual pleasure, and c) imposed at the insistence of males. Facts rarely correct that misunderstanding when presented. Most often the avoidance rests on imagined parental intent, as if that alone can dictate the outcome.

Modern evidence:

– Female genital cutting is embedded in a long history of oppression of female sexuality, and has as its main goal to diminish women’s sexual enjoyment. Male genital cutting in the form of circumcision has no such goal.

She is citing an objection from the comments of her original post rather than her opinion. She supports the challenge to the claim with the 19th century history of male circumcision in America. That is relevant, but there’s modern evidence that circumcision seeks to control male sexuality. Last year Rabbi Mark Glickman wrote (my post):

… Unlike female genital mutilation, Jewish circumcision is not a way to limit or control the child, and it does not destroy sexual desire.

Many find the practice troubling, I believe, because it so dramatically distinguishes religious values from commonly accepted modern American ones. America idealizes nature; Judaism and other religions try to control it and improve it. …

There are other examples. Religion still seeks to control the child and his sexuality through circumcision. A lack of ill intent does not negate the control from circumcision or its intentionality.

In a cultural rather than ritual context, circumcision is still about control. Parents circumcise so the boy will “look like his father”, regardless of what the child wants. Parents circumcise so that his sexual partners will not be repulsed. (This is an indirect form of control of his future sexual partners.) Parents circumcise to avoid STDs, even though condoms are still necessary. All of this controls the child and his sexuality. The control of males through non-therapeutic genital cutting is rarely as extreme as it is for females, but it is real and occurs now. There is no need to rely on history. The analogy holds up here.

Sexual Control: Making a Permanent, Unnecessary Decision for a Child

It’s rare to find a blatant attempt to explore justifications for the use of male circumcision as a form of sexual control. From Thursday’s debate on SB12-090 (pdf) within the Colorado House Health and Environment Committee, State Representative Sue Schafer directed a request to Dr. Jennifer Johnson. Dr. Johnson testified against the bill, specifically, and child circumcision, generally. Within Dr. Johnson’s opposition, she discussed the nerve endings in the foreskin lost to circumcision. Rep. Schafer asked (audio, excerpted from the legislature’s archive):

Rep. [Lois] Court said earlier “there are no dumb questions”, and that we will speak in a respectful manner, but I’m concerned about the rate of teen pregnancy, the rate of date rape, sexual violence, and when you talk about more nerve endings in the penis, in the foreskin, I’m just wondering if there’s any risk of more sexual activity among young men, more male irresponsibility, so if you’d be good enough to comment on that.

That question isn’t dumb. It’s offensive and insulting. Her underlying implication is that, if non-therapeutic male circumcision could be shown to lower the occurrences of what she’s concerned about, that would dismiss the ethical concerns about negatively affecting male sexuality that apply to every male child circumcision. It implies that it’s acceptable to control male sexuality (i.e. permanently reduce it) to limit sexual activity during teen years. It implies that males may inherently be incapable of controlling their own sexual behavior. There’s also the possibility that her implications are targeted only at the poor, the subject of this bill to restore Medicaid funding for non-therapeutic circumcision. I suspect her concern is for the general application of circumcision upon males, not just poor males covered by Medicaid. Regardless, Rep. Schafer’s question exposes the issue and its connection to unquestioned parental proxy consent for male circumcision, a permanent, non-therapeutic surgical intervention.

It’s useful to have this clear example because it’s a common misconception that male circumcision of minors involves no control or attempted control over male sexuality. That’s a misconception because non-therapeutic male child circumcision is always control. The patient receives only someone else’s idea of what a “normal” penis should be. He can no longer exercise control over his normal, healthy body, only his altered body. The flaw is most commonly some form of drivel about the preferences of the boy’s future sexual partners, which is speculation, but it applies to religious justifications, as well. Someone else imposes what the child “should” want. The truth is clear: all non-therapeutic child genital cutting controls sexuality.

The challenge to defeating the common misconception rests on separating parental intent from the act. The accepted argument entails the idea that male genital cutting can’t be something bad because the parents have good intentions. American parents think they’re doing what’s in the best interests of their sons, so we’re told we must accept that this negates the obvious reality of what the act is and does. That’s flawed because the act matters before we consider intent. Parents do not intend harm, but circumcision (i.e. surgery) causes harm. We can – and must – make a judgment on the act without regard to intent because it’s a non-therapeutic intervention on a non-consenting individual. It fails ethics.

Control: “to exercise restraining or directing influence over”

When I argue against non-therapeutic child circumcision, I’m strictly interested in protecting the child’s right to decide for himself. I do not seek conditions or expectations on what he “should” choose, or why. Everyone is an individual with his own preferences independent of what his parents prefer. The two may be similar, or even identical. In the case of ritual circumcision, I suspect that possibility is much more likely than not. But the two may not be similar. That’s what matters.

There is usually significant resistance to the statement that non-therapeutic child circumcision is mutilation. It is mutilation because it fits both the definition of the word and its consideration within the context of female genital cutting. In that context all non-therapeutic cutting is classified as mutilation. However, I do not suggest that the application of an accurate description implies anything about intent. I oppose forcing the surgery on someone who doesn’t need it and can’t consent, even though I accept that its imposition is well-intentioned. The problem is the cognitive dissonance involved.

Here is an example of cognitive dissonance by Rabbi Mark S. Glickman, commenting on proposed prohibitions on non-therapeutic child circumcision:

I know that the idea of circumcision may sound barbaric. But the practice is not. It is a loving way […]. … Unlike female genital mutilation, Jewish circumcision is not a way to limit or control the child, and it does not destroy sexual desire.

First, this opinion is not unique to religious circumcision. Every circumcision in America occurs under the mistaken assumptions that FGM is always ill-intentioned, that parental intent determines the outcome without regard for the action, and that male circumcision is not about control. These alleged distinctions have been repeated so many times that they’re incorrectly accepted as facts. They are not facts.

As the first excerpt suggests, the focus here is about intent. Rabbi Glickman claims that circumcision is not a way to limit or control the child. Yet, the next two sentences he writes are as follows:

Many find the practice troubling, I believe, because it so dramatically distinguishes religious values from commonly accepted modern American ones. America idealizes nature; Judaism and other religions try to control it and improve it. …

I’m confused about how trying to “control [his nature] and improve it” is not an attempt to control the child.

Here’s another example commenting on tweets from Russell Crowe:

That Crowe, who won stardom (and an Oscar) for playing a Roman gladiator, is unable to distinguish between real barbarism and a religious ritual that profits health is mildly dispiriting, especially when one of circumcision’s central aims is to curb male barbarism. Men are supposed to be reminded of God and, one could argue, moral behavior, in the very place they are most likely to betray religious ideals.

“Circumcision is the indelible symbol that a man can be more than just an animal,” Rabbi Ed Feinstein, senior rabbi at Valley Beth Shalom, said. “The fact that you seal your connection with God and with tradition into that organ makes it incredibly difficult for that organ to be used as a weapon of manipulation or destruction. For men, this is the center of being: Is masculinity to be defined in terms of power and violence, or control and strength? What you see in the news is what happens when men make the wrong choice.”

To be clear, I do not believe that circumcision as a form of control is exclusive to Jewish (or religious) circumcision. Control is inherent in every forced, non-therapeutic circumcision. Typical American reasons offered for circumcising healthy children are also control. Whether it’s to make the son “look like daddy” or to make him appealing to his future sexual partner(s), the message is clear. The way he is born is not acceptable. Someone has to make him better, a subjective concept, regardless of whether or not he wants to be made “better”.

Even circumcising to reduce his risk of certain future ailments is a form of control. It’s an indication that he isn’t capable of practicing sufficient hygiene or engaging in safe, responsible sex. It’s an unintentional declaration that “I know better than you what you need”. During childhood, that’s parenting. When it extends permanently beyond childhood, without chance for the individual to choose differently, it’s control.

Note: Title definition.