Category: FCD

Flawed Circumcision Defense: Wesley J. Smith

The Norwegian ombudsman for children’s rights recently stated about ritual circumcision:

[Pediatrician] Dr. Anne Lindboe told the newspaper Vart Land last month that circumcision in boys was a violation of a person’s right to decide over his own body. “Muslim and Jewish children are entitled to the same protection as all other children,“ she said. She added that the practice caused unnecessary pain and was medically unbeneficial.
…

The children’s ombudsman is an independent governmental institution entrusted with safeguarding the rights of minors.

Yes. Her statement is similar to the ruling from Cologne that non-therapeutic child circumcision violates the child’s rights to bodily integrity and self-determination.

That logical statement is meeting resistance. Over at Secondhand Smoke, which claims to be a “24/7 Seminar on Bioethics and the Importance of Being Human”, Wesley Smith revealed that he doesn’t much understand how non-therapeutic circumcision involves bioethics¹ or that having a normal anatomical body part is part of being human. In response to Dr. Lindboe, he wrote:

First, circumcision after the start of puberty is far more risky and complicated than infant circumcision. …

Perhaps. It’s also unlikely to be necessary later. The real consideration is between guaranteed pain and harm from the unnecessary surgery on an infant and it being riskier and more complicated as an adult in the unlikely event it’s needed. If a male chooses non-therapeutic circumcision, ritual or not, as an adult, he is expressing that he values the possible benefits more than the risks. Consent is the issue. (There are also advantages to waiting, such as not needing to forcibly separate the foreskin from the glans and having a larger penis to better measure how much skin to remove.)

He continues:

… But more fundamentally, religious liberty is one of the world’s most important freedoms. …

Yes, but there are other freedoms, such as the rights to bodily integrity and self-determination. They’re also important. And children possess their own individual right to religious freedom.

… For you secularists who don’t care, it seems to me that means that you only care about liberties you want for yourselves–which isn’t freedom at all.

First, that’s ad hominem. Second, he’s wrong. It’s possible to care about many freedoms at the same time, and for all people equally, including children. It’s possible for secularists to care about religious liberty possessed by parents while recognizing the ethical flaws inherent in non-therapeutic child circumcision that place the surgery outside the scope of individual religious liberty for parents.

The attack he perceives is misunderstood. (See also.) An attack on religious freedom would require an effort to prohibit religious circumcision, full stop. The current facts have been presented that way, which is incorrect (for whatever reason that misrepresentation occurs). The effort here is to prohibit non-therapeutic circumcision on a child who can’t consent. It aims to leave each child with his choice. He retains his right to have himself circumcised for religious (and/or non-religious) reasons. He may exercise his freedom of religion rather than having it exercised for him by his parents.

This necessary change will require religion to accommodate a different understanding of religion’s interaction with individual civil rights. That can and should be debated. As evidenced by Mr. Smith’s words, he hasn’t engaged that debate yet.

But if we believe that religious liberty is fundamental–it is, after all, a core part of the Universal Declaration on Human rights–then Jews and Muslims have a right to circumcise their children. [ed. note: males only?] Indeed, it is a religious imperative. …

It’s consistent to believe that religious liberty is fundamental and that no one has a right to circumcise their healthy children. It may be an imperative, but that alone grants no right.

Here is another core part of the Universal Declaration of Human Rights (emphasis added):

Article 1.

  • All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood.

Article 2.

  • Everyone is entitled to all the rights and freedoms set forth in this Declaration, without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status. Furthermore, no distinction shall be made on the basis of the political, jurisdictional or international status of the country or territory to which a person belongs, whether it be independent, trust, non-self-governing or under any other limitation of sovereignty.

Article 3.

  • Everyone has the right to life, liberty and security of person.

Mr. Smith writes as if other rights aren’t implicated by the exercise of religious freedom. The rights expressed earlier, and clearly, in the Universal Declaration of Human Rights are strikingly similar to those expressed by the District Court of Cologne and Dr. Anne Lindboe. It is clear that he is wrong rather than those with whom he disagrees.

To close he cites this essay by David P. Goldman, which deserves a post of its own rather than an analysis here. After the excerpt, Smith writes:

It doesn’t matter whether the Norway ombudsman or any of us agree. Circumcision is a sacred duty for Jews, a rite that brings the infant into the community. I assume the same is true for Muslims. In the name of freedom, government must leave it alone.

In the name of freedom, a legitimate government must protect the rights of all citizens equally. Because non-therapeutic child circumcision violates various rights of the child and inflicts permanent physical harm in every instance, prohibition is the only means to promote individual freedom. That is the proper role of government.

¹ The issue is more complicated than parental intent or imperative because there are competing rights. It’s further complicated because very few advocates of circumcision acknowledge what the surgery does to the (healthy) child.

Flawed Circumcision Defense: Waxman, Lowey, Berman, et al.

Twenty members of Congress sent a letter (PDF) to German Ambassador to the United States Peter Ammon. It’s a standard pro-circumcision talking points effort without any thought and without any acknowledgement that a (better) counter-argument exists. It’s the view of people living in a fantasy world. From the press release (emphasis added):

The letter, which was sent to German Ambassador to the United States Peter Ammon, objects to a June 26, 2012 decision in the District Court of Cologne as an affront to religious freedom because Jews and Muslims consider circumcision a fundamental rite of passage and affirmation of faith. …

It should be an affront based on objective criteria. In addition to the issue being a fundamental rite, circumcision is harmful to the recipient in objective ways. Prohibiting its imposition on a non-consenting individual (e.g. a child) would be an affront if the second issue were not involved. It is. This is an issue of competing rights. The District Court of Cologne ruled on that basis. These members of Congress, incorrectly meddling in the legal and policy affairs of another country, do not address the court’s ruling in their letter. They do not engage the facts.

For example, the press release concludes:

“A not so veiled assault on tenets central to religious expression is underway in Europe’s courts and legislatures,” added Rep. Berman. “We must let it be known to our friends in a clear and unequivocal voice that such measures are harmful assaults on religious freedom and should not continue.”

An attempt to regulate an activity is a “harmful assault” on an idea. I can accept that as a possibility, although the idea can’t be injured. It isn’t happening with a prohibition on non-therapeutic child circumcision. There is no assault on a valid freedom, just a child being injured during a non-therapeutic surgery. That is the only harmful assault involved. The Representatives are pushing empty platitudes as public policy at the expense of the rights of citizens.

For the letter itself, it’s linked above. I urge everyone to write a letter in response, especially if one of the twenty members is your representative. But we must remember to be respectful. Stick to the ideas. Do not engage in ad hominem or insinuation based on superficial factors. Focus on their words and how they contradict logic and equal human rights.

Strong and Non-Conflicting Evidence

A few days ago in the Huffington Post Canada, Sheryl Saperia defended non-therapeutic male child circumcision against the German court ruling. The title of her essay is “Male Circumcision is Not Mutilation, Period.” She is wrong.

After a bit of setup, she states:

For instance, neither the right to security of the person nor to gender equality should operate in such a way as to proscribe male circumcision on the grounds that it is comparable to the justifiably prohibited custom of female genital mutilation (FGM).

The two are ethically comparable. They are both non-therapeutic genital cutting on a non-consenting individual. That’s the comparison. It applies to every scenario.

But ignore the comparison. She’s jumping to the “FGM is worse, so male circumcision is okay” defense. Truncate her statement to the minimum necessary facts to understand male circumcision and the content of the ruling. Do male infants have the right to security of person? Assuming she answers correctly, that males possess this right, then non-therapeutic circumcision violates that. It is surgery, and without the recipient’s consent. It inflicts harm. Sometimes that harm is greater than what is expected, and in thankfully-rare instances, it can be fatally so. But it always involves harm. The right to be secure in one’s person should include protection from unnecessary, unwanted harm for all children.

She continues:

FGM is sometimes termed female circumcision, but this is a misnomer as it implies a minor operation equivalent to male circumcision. According to Doriane Coleman, a Duke University law professor whose expertise is children and the law, “This analogy can and has been rejected as specious and disingenuous, as the traditional forms of FGM are as different from male circumcision in terms of procedure, physical ramifications, and motivation as ear piercing is to a penilectomy.”

The term female circumcision is a misnomer for semantic reasons, but also because, as she indicates, it fails to fully explain what FGM does. However, semantic accuracy of male circumcision does not prove that male circumcision cannot also be mutilation. Saying it’s not FGM isn’t enough.

Contrary to Professor Coleman, the analogy is neither specious nor disingenuous. It is not based on merely the traditional forms. The traditional form of FGM differs across cultures. The question of which version we should use exposes the flaw in the tradition approach. The varying extent of damage can be reflected in the codified punishment for violations.

It makes more sense to start with the principle involved. Again, non-therapeutic genital cutting on a non-consenting individual is wrong. The principle does not require equivalent damage for both to violate the principle. Anyway, the anatomical analogy to mnale circumcision is a hoodectomy. The latter is illegal, which brings in the topic of equal rights. The law does not protect the rights of male minors that it protects for female minors.

The motivations aren’t as different as suggested, either.

Next:

The World Health Organization is also clear that:

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

I prefer my fact sheet because it deals with principles and equality rather than outcomes. Still, even on the appeal to authority she begins here, she’s wrong. Within its fact sheet, WHO states:

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

To repeat myself, would WHO rebrand female genital mutilation to “female genital cutting” and declare it an acceptable parental choice if some health benefits were found? I find the possibility doubtful, at best. So why shouldn’t we also apply the basic logic of harm as “removing and damaging healthy and normal genital tissue, and interferes with the natural functions of bodies” to males? It’s okay to do this without their consent because we’ve pursued a “health benefits” justification for enough years, even though almost every claimed benefit can be achieved with less invasive preventions and/or treatments?

Ms. Saperia quotes a 1997 joint statement from several groups declaring “FGM to be universally unacceptable, as it is an infringement on the physical and psychosexual integrity of women and girls and is a form of violence against them.” Even if we pretend that there is no psychosexual violation to males, there is the clear infringement on their physical integrity. (She returns to this point later, although she furthers her error.) Circumcision is a form of violence against males. It inflicts some level of harm in every instance.

Instead of acknowledging this connection, she quotes the WHO to push the irrelevant facts about circumcision being a long-standing practice and that many reasons exist for its imposition on healthy children. And then the predictable argument about HIV, which is easily refuted, and also countered with the truth that condoms are still necessary after circumcision.

She proceeds into the illogical “no real harm”:

In the absence of strong and non-conflicting medical evidence that male circumcision regularly causes substantial harm to young boys, the arguments against the procedure are severely weakened. …

Substantial is a subjective word. What one person finds substantial, I might not. And vice versa. The core question is whether or not there is non-conflicting medical evidence that non-therapeutic male circumcision causes harm. There is. It causes harm, in every case. Normal, healthy tissue is removed. Nerve endings are severed. The resulting scar provides further proof, and the mechanical functioning is altered. I accept that many people think this trade-off is acceptable for the possible benefits. But only the individual male is qualified to make that evaluation for himself.

… Since male circumcision and FGM are simply incomparable, gender equality should not demand the banning of the former just because the latter is illegal. [ed. note: Again, they’re comparable in principle (and to an extent within FGM Type IV). The law should reflect that.] And while the right to security of the person is certainly implicated by circumcision, the low risk of harm (and the fact that most complications are extremely minor) means that this right should be balanced against other compelling rights, such as religious freedom.

There is not a “low risk of harm”. There is a 100% risk of harm. There is a low risk of complications, of unexpected outcomes. Those harms are not the same. There is no implication. The guaranteed harm of non-therapeutic circumcision violates the child’s right to security. That should be balanced against competing rights, but as the court found, a child’s right to physical security outweighs his parents’ supposed right to practice their religion. From an individual rights perspective, the parents’ religious freedom ends where the child’s body begins. The child also possess a right to religious freedom.

After a paragraph praising the unity the three major religions are showing in their criticism, she writes:

According to the German court, the right to religious freedom “would not be unduly impaired” because the child could later decide for himself whether to have the circumcision. Aside from the court’s interference with a religious precept that the ritual must take place long before adulthood, the judgment could ironically cause greater harm to one’s bodily integrity because circumcision for adolescents and adults, as compared to infants, is more complicated and has a higher rate of adverse effects.

First, civil law already interferes with many religious precepts because they involve harm to others. Interference is not necessarily improper.

To her point, the issue is consent to the harm inflicted. The right to bodily integrity involves the ability to consent to harm. Or not. If a male wishes to get himself circumcised, he can decide for himself that whatever benefits he values from non-therapeutic circumcision outweigh the harm and risks of further harm. Or not. The perceived increase in difficulty in adults is not an ethical argument in favor of infant circumcision.

Within the religious context, we need to evaluate the number of teens and adults who would volunteer for ritual circumcision if left intact from birth. I assume that number would be very high. I do not believe it would be 100%, at which point the implications to individual rights should become obvious. More on this in a moment.

Outside the religious context, the number of teens and adults who would volunteer for cultural circumcision if left intact at birth would be very low, as it is now. I also assume the number of medically necessary circumcisions would increase, but only on a volume basis. The percentage would likely stay low, apart from the consequences of unnecessary fiddling with the non-retractable foreskins of children by doctors and parents.

While there appears to be the difference between infant and adult circumcision Ms. Saperia cites, there are other differences. Consent is the largest, but there is also the ability to say how much skin the individual wants removed, if he consents. Does he want to keep his frenulum? As an adult, he can have greater amounts of pain management medicine, as needed. The case isn’t as convenient to their argument as proponents seem to believe.

Ms. Saperia’s conclusion calls for a recognition of community rights, within limits, to support multicultural acceptance and integration. This is lacking on medical grounds because it is objective harm for non-therapeutic reasons. It is lacking on legal grounds because analogous surgical interventions are treated unequally in law. It is lacking on moral grounds because it lacks the consent of the recipient. Every proof she attempted failed to demonstrate that non-therapeutic circumcision on non-consenting children should be permitted.

Flawed Circumcision Defense: Yair Rosenberg

In what appears to be an attempt at a GOTCHA! in response to the German court ruling, Yair Rosenberg offers a weak effort touting the potential benefits of non-therapeutic circumcision. He opens:

“Male circumcision is a highly significant, lifetime intervention. It is the gift that keeps on giving. It makes sense to put extraordinary resources into it.”

Who would you guess recently offered this paean to foreskin fleecing? A rabbi? An imam? Nope. Try U.S. AIDS coordinator Eric Goosby at a health convention last month for top officials from 80 countries.

This smacks down the logic of a German regional court that has banned religious circumcision, calling the practice a “serious and irreversible interference in the integrity of the human body.” …

Mr. Goosby’s statement, used as an appeal to authority, does not smack down the logic of the German court. Circumcision can impart potential benefits when it is imposed on a healthy child, while meeting the court’s statement that it is a “serious and irreversible interference in the integrity of the human body”. The imposition on a healthy child makes it unethical. There is no need for an allegedly-required belief that the science isn’t real. Mr. Rosenberg’s argument focuses on ends without a complete consideration of the means.

He next offers the inevitable appeal to a reduced risk of HIV. As almost every advocate does, he omits the relevant caveats. The risk reduction is in female-to-male HIV transmission in high-risk populations. Neither describes the HIV epidemic in any Western nation, including Germany. Even if it did, the studies involved voluntary, adult circumcision, not infant circumcision. That’s the ethical question. Infants can’t consent. They also won’t be having sex any time soon. There is no immediate need to force non-therapeutic circumcision on them for this potential benefit.

His next tactic is revealing. He quotes a story on the HIV studies. The story quoted unnamed federal health officials who declared that the studies were halted early because the findings made it “unethical to continue without offering circumcision to all 8,000 men in the trials”. Okay, fine, they offered circumcision to the control group. Mr. Rosenberg states:

Unethical not to circumcise the men.

No. Researchers deemed it unethical to not offer circumcision to the control group. That’s a huge difference. The control group men retained the right to reject circumcision. One might say this distinction is “highly significant”. Mr. Rosenberg seems to have missed the entire ethical issue. The issue is the imposition of circumcision, not whether or not someone could (or should) conclude that circumcision for himself is awesome because of various possible benefits.

He returns to an appeal to authority:

… The American Academy of Pediatrics is soon expected to come out with a new policy pushing circumcision, reversing its prior stance.

I’m not a fan of the “no medical association recommends it” argument because it’s an appeal to authority and because it could change. But the same problem applies to using a medical association’s support. In the latter case, it’s an evaluation without regard for what the individual needs or wants. It’s untethered from rights and reason.

He continues (emphasis added):

Given this impressive scientific consensus as to the medical dividends of male circumcision, the German court’s judgment—which permits circumcision for “medical reasons”—is a confused and ignorant muddle. Some have rightly criticized it as an assault on millennia of Jewish tradition and practice (not to mention Islam), something one would have thought a German court would be sensitive enough to avoid. But the ruling itself, as the research above amply demonstrates, is logically incoherent and factually wrong for a simple reason: All circumcisions are medically beneficial. Whether or not the procedure stems from religious motivations, it will have measurable health benefits. So by the court’s own reasoning, all religious circumcisions ought to be permissible as long as the parents also want the medical dividends—which effectively means that circumcision has not been banned at all. Of course, it is very unlikely that this is what the court intended and much more likely that it was entirely unaware of the scientific consensus surrounding circumcision’s advantages.

First, it seems clear that the court meant “medical reasons” to mean “medically necessary”. In saying that the court’s reasoning renders non-therapeutic circumcision valid based on merely mouthing the words “medical benefits”, he is echoing the silly argument many push that pretends prophylactic circumcision is “medical” circumcision. It is not. Non-therapeutic child circumcision involves proxy consent, not consent, so the only valid medical reason is need. As Mr. Rosenberg acknowledges, this interpretation is not likely the court’s intent. Assuming that this means the court was unaware of the science is too convenient. It begs the question. “They ruled circumcision is harm, so obviously they didn’t consider the benefits. If they had, they’d know that all circumcisions are medically beneficial and rule accordingly.”

Within either analysis, his conclusion is still wrong. The italicized bit is Mr. Rosenberg’s personal evaluation. It is his subjective conclusion based on his preferences. (He indirectly admits this later.) It is not an objective fact. The only objective fact is that circumcision inflicts some guaranteed level of harm. There is also the possibility of unexpected harm reflected in further complications, which contradicts his “all circumcisions” insistence.

Not everyone will value the potential benefits the way he does. I don’t. The HIV benefit he cites, the one that barely applies to Western societies, is effectively moot if a male simply wears a condom when he has sex. The same ease of prevention applies to HPV, for which there is also a vaccine approved for females and males already exists. And so on. The remaining benefits are generally achievable through less invasive preventions and/or treatments. The most invasive surgical option on children as a prophylactic measure can’t be justified ethically.

Or to put it in extreme terms, is circumcision medically beneficial to the boys who will lose more than their foreskin? What about the boys who die? Is circumcision medically beneficial to them? All circumcisions are medically beneficial, right?

He also misstates the goal of activists:

But that scientific consensus reveals more than just the follies of this German court; it also exposes the deeply problematic aims of American advocacy groups which seek to outlaw circumcision for the entire United States. …

The goal is to prohibit non-therapeutic circumcision on non-consenting individuals. It is not to outlaw circumcision, full stop. That’s his meaning, but precision matters here, just as it does when discussing the reduced risk of female-to-male HIV transmission in high-risk populations.

After trotting out the tired “why do you hate the poor?” argument, he writes:

… It’s one thing to abstain from a potentially medically beneficial procedure due to personal convictions; it’s quite another to enforce those convictions coercively on others.

Children who have circumcision forced on them do not get to abstain due to personal convictions. They had someone else’s convictions enforced coercively on them. If Mr. Rosenberg understands the ethical issues involved, he hasn’t shown it yet.

Ultimately, those who seek to ban circumcision as the essential equivalent of child abuse—from this German court to activists who recently attempted to bar the practice in San Francisco—are doing so in the face of tremendous scientific evidence to the contrary. Their claims are at odds with countless studies, not to mention global health policy. The burden of proof, then, is upon these activists to defend their disregard for this science, not on the majority of Americans who choose to circumcise their children and take advantage of its documented benefits.

This isn’t how the burden of proof works, since proponents of non-therapeutic circumcision on non-consenting children are the people advocating intervention contrary to the normal, healthy body. It warrants an answer, regardless. I do not disregard this science. I accept it all. I just don’t foolishly pretend that the possibility of a benefit permits me to disregard ethics or the vast amount of science beyond claimed benefits from non-therapeutic circumcision. The normal, healthy foreskin is science. The ability of soap and water to cleanse the penis, foreskin included, is science. Condoms are science. The power of antibiotics to treat infections is science. If we are to take Mr. Rosenberg’s narrow reasoning as a valid replacement for ethics, any surgical intervention on a child becomes acceptable if some rationale about possible benefits can be found. There is no limiting principle that respects rights. It’s based on one’s preference for circumcision about one’s child, without regard for what the child needs or might (not) want.

He concludes¹ with this:

After all, individuals are free to discount scientific evidence on the basis of value considerations, even dubious ones, and base their life decisions upon that calculus. But such subjective notions should never form the basis for coercive state policy any more than, well, religion.

Individuals are free to discount scientific evidence on the basis of value considerations. I do. I accept the benefits, but I value other aspects of the issue more. Ethics, bodily integrity, and normal body parts all matter more to me than the possible benefits. Whether that’s dubious or not for me is not for anyone else to decide. Yet I don’t have any freedom on this. My parents had me circumcised. They made my decision on their subjective calculus. It was the basis of their coercive parental policy. If the issue is force, and it is, the only illegitimate force exercised here is circumcising healthy children. Prohibition is the defensible position.

If we want to discuss whether prohibition is the best approach to solving the violation of non-therapeutic circumcision on non-consenting individuals, that’s a discussion worth having. Cultural change is likely to be far more effective. Society, in general, and religions, specifically, have changed. There’s no reason to believe it can’t happen here. It should. It will. In the meantime, though, children are having their decision made with force. Agitating for change through multiple avenues, including the law, is reasonable.

¹ He actually concludes with “Your move, Foreskin Man.” That’s not an argument. I’ve written what I need to say on that topic.

Flawed Circumcision Defense: Dr. Ruth Westheimer

At the risk of being impolite to Dr. Ruth Westheimer on her birthday, here’s a reminder of how lacking her position on male child circumcision is. From an advice column from 1995:

Dear Dr. Ruth: There is a good deal of anti-circumcision opinion in circulation these days and I would like to get your opinion. One of the claims is that circumcision results in a reduction of sexual pleasure. The argument, which sounds logical, is that exposing the glans reduces its sensitivity and that therefore the uncircumcised penis affords more sexual pleasure than the circumcised one. Sounds plausible, but is it true?

I think that many of today’s young parents, Jewish and others, who like to do what is “politically correct” might well forgo circumcision of their sons if that condition would mean someday depriving them of a measure of sexual pleasure.

Can you suggest any kind of evidence which either supports or challenges this claim?

Dear Reader: While it is true that one of the long-term effects of circumcision is some loss of sensitivity in the glans, or head of the penis, what you must realize is that sex really takes place in the brain, and so long as the man is in a loving relationship, there will be many compensating sensations taking place in his brain to replace those he might have lost in his penis.

She answers the question correctly (with an answer contrary to the mistaken opinion many hold today, almost 17 years later). While I understand what she’s doing, using the bulk of her answer to disregard the implication of her initial statement is inexcusable. The question involved children, not how to comfort a circumcised adult sexual partner. This disregard is still all too familiar today. “It affects his sexual pleasure, but…” There is no valid defense of that “but” for non-therapeutic circumcision on a child.

On her website, she answered another circumcision question. It’s undated. I assume it’s (considerably) more recent than 1995. It doesn’t matter. (emphasis added)

[Reader:] My wife and I are expecting, and we are not finding out the sex. However, if we have a boy, she is adamant that we not circumcise him, and I am adamant that we do. I have researched article after article about the hard medical facts of circumcision and how it lowers the transmission rates of STD’s such as HIV. It also helps with penile carcinoma, UTI’s, and ulcerative STD’s.

My intelligent wife believes that we should offer our son a choice of whether he wants it or not, and is afraid our son will feel the pain if he has it.

I am circumcised, and want my son to ‘look’ like daddy, as well as not have to explain to him at a younger age as to why he is so much different than daddy.

I’m interrupting here to highlight what is obvious. The father talks about all of the benefits he has researched. Yet, his statement makes it clear that his real reasons are that he wants his son to look like him and to avoid the need to parent his child with an explanation for why his son is “different” (i.e. normal). This is even though a son won’t ‘look’ like daddy for at least a decade after circumcision, which he will still have to explain if it comes up. Better to act like a parent and explain his normal, healthy body to him than to pretend that his dad’s insecurities justify surgery. (These insecurities will appear again.)

Furthermore, if the procedure is done later, our son will be in pain for six weeks, and I just don’t want him to have to endure that torture. [ed. note: so it’s acceptable to force him to endure that as an infant?]

As circumcision requires both parents consent, this matter will not resolve itself. I feel that my wife should consent as I have more experience in this matter than she does. [ed. note: This is stupid. Would he abdicate his responsibility as a parent if his wife wanted their daughter cut?] I would also feel inferior when our son asks, ” Daddy, why did you cave in to mom’s demands?” later in life. [ed. note: Protecting your children from harm is the “manliest” thing a father can do. Don’t pretend this is about proving your power and ego.]

We are at an impass. We are both passionate about our beliefs (she would consent to having our son circumcised if I were Jewish). What can I do? Should I let this battle go?

Before getting to Dr. Ruth’s answer, I didn’t interject into this man’s question to mock him. I only seek to indicate how obvious the rebuttals are that a good advice columnist would offer about this parenting question. His approach is quite common, so it shouldn’t be unfamiliar to Dr. Ruth. She didn’t go that route, of course.

[Dr. Ruth:] While it’s OK to have differences of opinions, I would hope that you don’t have to have actual battles over these issues. Perhaps because you’re both acting so stubborn, neither one of you is willing to listen to reason. And at this point, you don’t even know if it’s going to be a boy or a girl!

While you raise good points regarding the health concerns, those risks are greatly reduced if it is a boy and you teach him to clean his penis thoroughly. [ed. note: Indeed.] I know not every young male does a good job at that, but if this is important to you, then you’d just have to make it your duty to make sure he does. [ed. note: Parenting… What a useful answer.]

Your wife’s point that the decision should be his does not sound very intelligent. It is much worse to have this procedure when you are older, so the decision must be yours when he is quite young. If that’s her only concern, then perhaps your argument that you want his penis to look like his dad’s has more weight. But in the end, this is not such an important issue and rather than fight over it, you should have some reasonable discussions, if the baby turns out to be a boy, and see what happens. But better to lose this particular debate than fight with your wife.

Dr. Ruth’s last paragraph is a complete mess devoid of ethics. The wife’s point is the only intelligent opinion uttered throughout. As Dr. Ruth answered in another question (about an adult), “[i]t’s his penis …”. Yes. In that other question, if the argument that it’s his penis weren’t the correct answer, Dr. Ruth should’ve told the woman asking that question to demand that her boyfriend get circumcised. She didn’t. Self-ownership exists from birth. It is not negated simply because a boy’s parents fear a possible future outcome.

That gets to Dr. Ruth’s next failing here. She omits the critical point. What is the risk he will need to be circumcised later? It’s quite low, of course. In addition to the more important fact that there is no decision to be made now, there will likely never be a decision that needs to be made. Whether or not he might deem the prospects of adult circumcision to be worse is irrelevant. It does not mean the decision must be his parents’. Dr. Ruth’s opinion is not intelligent. Justifying cosmetic surgery on a son to appease his father’s ego is not intelligent, either.

(Her last sentence is an accidental correct answer. She found her way to a good suggestion premised on an awful reason.)

Flawed Circumcision Defense: Mitchell Warren

Mitchell Warren, the Executive Director of AVAC, penned an essay at the Huffington Post titled The “Best Hope” for AIDS Vaccine Advocacy. If it was just that, it would be fine. It’s not just that because it never is, although it takes digging beyond the article itself to find the problem.

He begins this essay about searching for an HIV AIDS vaccine:

There is growing global momentum behind the call to begin to end the AIDS epidemic using the scientifically-proven options available today. These include voluntary medical male circumcision, antiretroviral therapy (ART) — which dramatically reduces risk of HIV transmission between stable sexual partners — and prevention of pediatric infection during pregnancy, delivery and breastfeeding. If taken to scale with resources and urgency, these core components of combination prevention, along with other key prevention interventions, can save lives, prevent new infections and lower the price tag for the global AIDS response over the long term.

Well, sure, if we’re talking voluntary medical [sic] male circumcision, there isn’t an immediate problem. Such a strategy works to re-enforce and extend infant male circumcision in the long-term, and that needs to be addressed. But, by itself, voluntary medical¹ non-therapeutic male circumcision is a choice an individual may make for himself.

That’s never where it ends. AVAC describes itself (emphasis added):

Founded in 1995, AVAC is a non-profit organization that uses education, policy analysis, advocacy and a network of global collaborations to accelerate the ethical development and global delivery of AIDS vaccines, male circumcision, microbicides, PrEP and other emerging HIV prevention options as part of a comprehensive response to the pandemic.

Its focus on ethics is so robust that it randomly drops voluntary from “voluntary medical male circumcision” on its circumcision page. Its focus on ethics is so sincere that AVAC once issued a press release quoting Mr. Warren supporting:

“Research and dialogue are also needed now to explore the feasibility of rolling out infant circumcision. This approach will not show immediate benefits in terms of HIV incidence but can minimize risks and could be a highly cost-effective implementation strategy over the long term.”

To be fair, that press release is more than five years old. But the site also includes a link to a 2010 paper co-written by Brian Morris titled, “The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV”. And the Women’s HIV Prevention Tracking Project (WHiPT), a collaborative initiative of AVAC and the ATHENA Network, released a report (pdf) in December 2010 titled “Making Medical Male Circumcision Work for Women”. Question: why is voluntary missing in voluntary medical male circumcision? The report, as suggested by the missing “Voluntary”, is full of YAY INFANT CIRCUMCISION. For example, on page 9, under Next Steps for WHIPT Advocacy based on the findings:

Over the next year, WHiPT teams will execute advocacy plans based on their findings. Actions include:

  • …
  • Investigating the benefits and disadvantages of infant male circumcision

So, AVAC’s notion of ethics includes the ability for one person to “volunteer” another person for non-therapeutic surgery. I’m not surprised. It’s page on ethics includes:

The term ethics addresses ideas of right and wrong and with moral duty and obligation. Research ethics address “rights” and “wrongs” surrounding research that uses human participants to find answers to scientific questions. The primary focus of ethics guidelines for research in humans is safeguarding the rights, dignity, and health of the trial participant.

What about the ethics of applying the findings of research to non-consenting, healthy individuals? That is also a valid question that AVAC is apparently willing to ignore. Or should I read its position to mean these ethically-developed strategies are to be applied globally without further concern for ethics in applying those strategies? My analysis would be irrelevant in that reading. Of course, AVAC would still be very unethical, but my analysis would be wrong. I’m not that cynical, so I don’t read it that way. Onward.

The WHiPT report continues with its recommendations for Kenya (page 15):

The Ministry of Health should consider the integration of MMC for infants into the maternal and child health facilities, given the long-term benefits as well as the safe and inexpensive nature of the procedure.

I’ll ask again: why is the “V” missing in VMMC? Of course it wouldn’t make sense when talking about infant circumcision because that’s not voluntary. But the ethical position is to drop infant circumcision, not voluntary. The latter is just a matter of convenience in pursuit of an improperly-stated goal. (An improperly-stated goal could also be called “lying”.)

In its Uganda findings (page 55):

Almost one-third of the respondents said they would circumcise their infant boys if MMC were protective against HIV (33.3 percent for Kampala and 27.8 percent for Kapchorwa).

From its conclusion and recommendations for Uganda (page 57):

From the documentation, it is clear that women are aware of traditional/religious male circumcision but have little knowledge of MMC and its benefits to them. On the same note, women are not empowered in decisionmaking around MMC—with either their spouses or their infants. Policy makers should consider the social and gender implications of MMC in the community, if it is to be appreciated and beneficial to both men and women.

MMC acceptability and use in communities revolves around promotion, advocacy and sensitization efforts undertaken by the government, implementers and advocates.

  • Government and advocates must provide increased sensitization of women, with enough clear information about MMC before the community is prepared for its uptake.
  • Government, advocates and community leaders need to address the myths and bring facts about MMC with evidence-based information to communities.
  • Government and implementers must develop an MMC package that will integrate sexual and reproductive health with gender equity and empower women to get involved in decision-making, especially on condom use.
  • Implementers must impart knowledge and skills in decision-making regarding the circumcision of their male infants.

The “V” is missing everywhere. I’m starting to think the “V” key must be broken on every keyboard AVAC to which AVAC has access. That, or they only care about circumcision without regard to the ethics of voluntary action.

For further demonstration of the point, from the findings and recommendations surrounding the conflation of voluntary medical male circumcision and female genital mutilation, the report states (page 8):

• Advocates must monitor efforts to clarify the distinction between MMC and FGM.

There are distinctions in degree, which is what the researchers intend as proof that the difference is in kind. They are wrong, but temporarily, let’s accept their mistake as valid. Even with that requirement, there is one distinction between MMC and FGM that can’t be made, despite the group’s expectation that this distinction is obvious. Neither MMC nor FGM is voluntary. Both are forced on the recipient (i.e. victim) by another person. If the recommendation focused on the difference between VMMC and FGM, then the distinction would blink in neon. But they can’t include that because the entire premise of infant circumcision requires a complete rejection of the ethics of voluntary without regard for the defensibility of that rejection.

Basically, it’s clear that AVAC cares about the ethics of circumcision only as far as it’s useful in pushing circumcision. Where ethics permit circumcision, the concept matters. Where ethics reject circumcision, just drop the “V”. Circumcision is an AVAC objective, not ethical circumcision.

¹ I strike medical because the term advocates are looking for is medicalized, or something implying a sterile facility with modern surgical tools. I assume medical is also meant to convey the pursuit of potential benefits, but that too conveniently omits the ethical aspect of non-therapeutic circumcision. Thus, I have no interest in promoting loose wording.

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.

“Since not all men are willing to be circumcised,…” (Part 2)

Update (5/31/2012): To the extent appropriate, my update to Part 1 applies here. I have not edited anything in this post, though. [End Update]

Note: Here is Part 1 of this series rebutting the recent meta-analysis purporting to demonstrate that infancy is the best time to impose circumcision on healthy males.

The interesting thing about the Brian Morris, Jake Waskett, et al article, “A ‘Snip’ in time: what is the best age to circumcise?”, is how reckless they are with their logic. They toss out information without regard for obvious rebuttals or how unrelated the so-called evidence is to their conclusion. If they think it might stick, they include it. One can only conclude that they started with the outcome of their analysis before gathering the supporting data.

For example, in their conclusion, they write that early circumcision “means an assurance of greatly reduced risk of penile cancer later in life, no smegma, better hygiene, and lower risk of various STIs.” They don’t include anything on why smegma is supposedly bad and thus indicates circumcision is not only good, but should be imposed on healthy infants. I’m sure they can find something, although I doubt it would be compelling. There’s also the logical question of why it’s an indication for non-therapeutic genital cutting on boys but not girls, who also develop smegma.

They continue this effort in their conclusion. In a sub-heading they write:

Some of the arguments against waiting until later to circumcise are:

• The cost (to the individual or the public purse) is much higher, and often unaffordable, for later circumcision.

The cost to the individual who doesn’t need circumcision later in life is zero. That population would be very large for males left intact. Even from the irrelevant “public purse” approach, they would need to calculate the cost of therapeutic circumcision paid for by they public later in life against the cost of non-therapeutic neonatal circumcision (cost per instance X number of instances). They don’t.

Also, the time value of money must be factored into the comparison. A dollar spent today is not the same as a dollar spent twenty, thirty, or more years from today. The number of adult circumcisions needed would have to be even greater to justify their public purse argument. It still wouldn’t be ethical to circumcise healthy infants, of course.

That’s not the worst “argument against waiting” they offer. This is:

• Educational resources for boys to make an informed decision are quite limited.

I had to read this several times to be certain it said what I read. They can’t be this ridiculous. They are.

The immediate, obvious rejection of that nonsense is that boys (and adult males) can use the same educational resources Morris, Waskett, et al suggest parents use to make an “informed” decision. Surely they exist, or else the position that parents can make an informed decision without adequate educational resources is irresponsible. What makes the male himself too stupid to understand the same materials? There’s no defense for their statement or their conclusions.

They offer a few more:

• Boys who later choose circumcision will likely wish it had been circumcised in infancy.

This is the bizarre argument I’ve encountered from Waskett, the mythical “right” to grow up circumcised. But this is the radical position. Boys who would later reject circumcision can’t undo the harm imposed on them. The authors incorrectly dismiss this. It is the center of both the physical and ethical argument against non-therapeutic child circumcision.

• Many older boys and men may not want to face an operation even though they wish to be circumcised.

That ties to a statement earlier in their article:

Even if a man is willing to be circumcised this does not mean he will end up having the procedure done. On the other hand, a lack of willingness to be circumcised should not be interpreted as a preference to be uncircumcised. This is because a large number of obstacles have been documented, such as fear of pain or complications, embarrassment, inconvenience and cost. The obstacles are discussed in the following sections. It is reasonable to suppose that, if these barriers could be addressed through the provision of correct information and financial assistance, the fraction of men willing to be circumcised would increase significantly. Better education of parents before or soon after their baby is born about actual risks should, by helping to ensure a circumcision in infancy, avoid later deliberations and barriers to circumcision in adolescence and adulthood.

That’s very convenient for their preference. Just assume anything that helps your position and disregard anything the suggests something else. Notice the shift in that paragraph. The last sentence of that paragraph has zero relation to the rest of the paragraph. A male’s refusal to be circumcised despite a claimed desire to be circumcised demonstrates that he values avoiding the costs more than receiving the benefits. The only reasonable supposition is that the infant would likewise be unwilling to undergo circumcision if left his choice. The authors’ suggestion is nonsense.

There is at least one more installment to come.

What Applying the Science Says About Circumcision

It’s frustrating to read people writing about the science of non-therapeutic infant circumcision while omitting ethics and a full consideration of what constitutes harm. Such is the case with a series of posts at SquintMom. The blogger, Kirstin, is doing a series of three posts, “What the Science Says About Circumcision”. Part 1 on the benefits is here. Part 2 on the risks is here.

I have a lot to say on the two entries posted so far, but I’d rather organize my thoughts into identifying a more generalized flaw in the series. As I said, this is primarily the ethics of applying the science. Several times in Part 1, she uses parentheticals to explain the circumcised men in the studies. “With their permission”. “With their consent”. This matters. She concludes that there aren’t enough benefits to support routine circumcision in the U.S., which is the right conclusion. But her assumption seems to be that some level of benefit could justify routine infant circumcision. That’s too utilitarian. Individuals have different levels of risk aversion. A male’s willingness to accept risk may be greater than his parents’. We can’t know. Even if our HIV problem in the U.S. matched that of sub-Saharan Africa, I wouldn’t want to be circumcised. I’m responsible. I do not need circumcision to reduce my risk beyond the trivial risk I would face. No level of benefit could justify circumcising me without my permission and consent.

A willingness to carry “I don’t know” through its implications is the better conclusion for Part 2. That’s not what she offers. It’s incorrect to say “[i]t’s fine to make a decision based upon values”, as she did in her intro to Part 1. Circumcision causes physical harm, contrary to her conclusion. That she thinks that isn’t “significant”, a subjective word in the application of the science to healthy individuals, isn’t relevant to what we should allow parents to do to their – male, only¹ – children. What does the healthy male want? She mistakenly gives this no weight in her conclusion.

On the topic of harm, it’s worth starting on the legal point. Legally, all surgery is battery. Circumcision is surgery. Therefore, circumcision is battery. It is physical harm. It removes the normal, healthy foreskin. It involves risks, however insignificant they may seem to anyone other than the patient. Someone will be the statistic. He matters, too. (Again, this omission is why utilitarianism is awful.) It leaves a scar in every case. There is objective, guaranteed physical harm. To conclude that there is no physical harm to every circumcised male rather than just those who experience complications, as she did, is factually incorrect.

The legal defense to surgery as battery is consent. But non-therapeutic infant circumcision involves proxy consent, which requires a different standard. The objective is least invasive procedure possible that preserves the patient’s choices to the greatest extent possible. Since there is no procedure indicated because the child is healthy, there is no decision to be made. Permitting non-therapeutic circumcision is unethical. To address SquintMom’s recent post, “Options, Ethics, and Moral Imperatives”, a society’s overarching social philosophy can be wrong. Here, it is because non-therapeutic (i.e. “routine”) child circumcision involves objective, permanent physical harm without objective benefit.

As an example of where SquintMom went astray, I think this is a solid example (emphasis in original):

While the foreskin has sensory function (Taylor et al), there is no scientific evidence to suggest that the loss of these receptors affects sexual satisfaction or the intensity of the sexual experience for men. One study even goes so far as to suggest that while there isn’t currently evidence to support the notion that circumcision somewhat desensitizes men, even if such evidence existed, it wouldn’t necessarily be a bad thing, given that more men (and their partners) complain of premature ejaculation than complain of inability to achieve orgasm (Burger et al). While Burger doesn’t go so far as to suggest circumcision to prevent problems with premature ejaculation, these observations do put into perspective the “intactivist” argument that circumcised men don’t enjoy sex as much as they otherwise would; clearly, for the vast majority of men, enjoying sex isn’t a problem. The scientific evidence does not support the notion that male circumcision diminishes sexual performance in men, nor sexual satisfaction in men or women.

First, note the utilitarianism again. The foreskin has sensory function, but no evidence suggests… More men complain of X than complain of Y. That doesn’t eliminate the possibility that a man will want that sensory function or the concern for Y and the individuals who experience that. (I do not assume it is a direct result of circumcision.) Apart from the obvious fact that the loss of that possibly irrelevant sensory function still constitutes harm, SquintMom’s statement implies that all men value everything in the same way, or that they “should” value X more than Y. That’s obviously false. I don’t like coffee. Therefore, you don’t like coffee. Valid?

Clearly, for the vast majority of men, enjoying sex isn’t a problem. Yep. So? The better response is to carry through the implications of “I don’t know”, since we can definitively say not all circumcised males will enjoy sex. Specifically, we need not go beyond the men who are the statistics, the ones who incur a complication that is severe. The number of males who lose their glans, their penis, or their life is small, but the number is not zero. Who is going to be that male? We don’t know. Permitting parents to cause harm by applying the science of “no scientific evidence of harm” to their healthy – male, only – children means there will be males who either don’t enjoy sex or don’t live to enjoy sex. Applying the science of “no scientific evidence of harm” also assumes we won’t find any evidence in the future. The truth is that we don’t know.

She mostly expresses this point (e.g. “untestable claim”), but it’s not complete. Even ignoring what I wrote above on harm, it’s not definitive from her case that there is no physical harm from male circumcision. There is the possibility we’ll know more. In proxy consent, it doesn’t make sense to then apply the science of today permanently to the healthy body of another person based on parental values.

**********

¹ In her first post, she prefaced the series with “[f]emale circumcision is a completely separate practice, occurring for the express purpose of destroying sexual function.” She is wrong on both positions. (She repeats the former in the comment section of Part 2.) Female genital mutilation is usually imposed with that purpose, but not always. Cultural behaviors are complex, as she points out in her series. Why should it be different on something we (rightfully) abhor? (c.f. Consider these three posts.)

Anyway, the comparison is non-therapeutic genital cutting on a non-consenting individual. It can’t be wrong for one gender but acceptable for the other. There is no parental right to cut sons. That’s a bizarre world in which males and females have unequal rights to their own bodies. There is either a parental right to cut the genitals of healthy children, or no such right to cut healthy children. We rightly call the removal of a healthy girl’s clitoral hood “mutilation”. There is no ethical, legal, or scientific distinction to avoid protecting the analogous healthy body part in males.

This is what the World Health Organization states on FGM. It consists of four types, including type 4:

Other: all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.

Surgical alteration of the normal human body is harm.

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

Would WHO rebrand female genital mutilation to “female genital cutting” and declare it an acceptable parental choice if some health benefits were found? I find the possibility doubtful, at best. So why shouldn’t we also apply the basic logic of harm as “removing and damaging healthy and normal genital tissue, and interferes with the natural functions of bodies” to males? It’s okay to do this without their consent because of cultural values? That’s absurd.

“Since not all men are willing to be circumcised, …” (Part 1)

Update (5/31/2012): I modified the first paragraph to focus my jabs. I should not have been as broadly rude as I was. I have great contempt for Brian Morris, but he should’ve been the only target for that contempt. The other authors merely frustrate me via either personal interactions or their public statements. In my interactions with Mr. Waskett, specifically, I haven’t experienced the contemptible behavior so easily witnessed from Morris. I regret that mistake.

A long list of familiar names have conducted a meta-analysis of a bunch of studies involving circumcision. The article purports to ask the question “What is the best age to circumcise?”. (Notice the implicit assumption that a male should be circumcised.) They don’t address that question, of course, instead answering “How can we encourage infant circumcision?”. They only justify it in their minds because their analysis is lacking. I didn’t expect anything better after seeing Brian Morris attached to it. (Jake Waskett, Aaron Tobian, Ronald Gray, Robert Bailey, Daniel Halperin, and Thomas Wiswell, among others, are listed as co-authors.)

I’ll probably post more extensive critiques because it all deserves as public an airing as possible. Their credibility deserves to be attached to this awful piece of scholarship. For now, I want to focus on this, from the section titled “Is infancy the best time medically?”. It offers a succinct example of their incomplete, flawed approach.

All boys are born with phimosis. This resolves by about age 3 in all but approximately 10% of males, who as a result experience problems with micturition, ballooning of the foreskin, and painful difficulties with erections (see review [9]). Paraphimosis can similarly be prevented by infant MC.

This is silly. All boys are born with phimosis? That’s a stupid way to explain normal human development. They’re pathologizing the healthy infant foreskin to justify the conclusion they want to reach. How many of those boys in the 10% will have their foreskin naturally separate (i.e. “resolve”) after age 3 and will never need any intervention to achieve this? They’re implying that an intervention is necessary for healthy, intact three-year-old boys whose foreskin hasn’t fully separated. (The whole paper is that, except stated rather than implied.)

Throughout the paper, they never consider the important question when reaching the conclusion that something can be “prevented by infant MC”: how many legitimate instances of phimosis/paraphimosis/UTI/whatever require circumcision later in life because another, less invasive intervention is insufficient. They declare that the risk in intact males “of developing a condition requiring medical attention over their lifetime = 1 in 2”. (I’ll grant that because it doesn’t alter the conclusion on non-therapeutic infant circumcision.) They never identify how many of those require circumcision. Yet they use this 50% figure as a justification for infant circumcision. The need for circumcision rather than the need for medical intervention is what’s relevant. Their focus is mistaken and leads to their incorrect conclusion.

In the “Cosmetic Outcome” section, they write:

When circumcision is performed in infancy the ability of the inner and outer foreskin layers to adhere to each other means sutures are rarely needed and the scar that results is virtually invisible [98]. Other factors include the more rapid healing at this time of life, contributed by age-associated differences in pro-inflammatory factors that might affect scar formation [145].

Once again they’re using normal human development to manipulate a path to their predetermined conclusion. They’re using a convenient aspect of the surgical procedure rather than medical need to justify imposing the surgical procedure.

The ability of an infant’s inner and outer foreskin layers to adhere to each other once cut also demonstrates that boys are not born with phimosis. This ability is evidence that the normal foreskin is not supposed to be separated from the rest of the penis at birth. Neither argument is a valid defense of infant circumcision, but the authors can’t have both in their attempt. Doing so is just a way of presenting the preferences they like as the only preferences worth considering. That’s biased by the authors’ utilitarianism. Remember when I wrote “[t]he utilitarian approach is subjective and has a tendency to favor whatever argument someone is making because it assumes all people favor the same choices”? Their article is a perfect example of that.

Since that ability is classified under “cosmetic outcome”, let’s discuss that. My circumcision healed the way they suggest. The scar did not heal “virtually invisible” for me. Any cursory review of pictures of circumcised penises will show that the scar is almost always quite visible. My complexion is very light, so I suspect my scar is less visible than what most males experience. But it’s still quite visible. They’re wrong. This error is inexcusable.

Perhaps the cosmetic outcomes of circumcision, infant or adult, are desirable to Morris, Waskett, et al. They’re entitled to their opinions about their own bodies. It does not follow that parents who share that preference may force those onto the body of a child – male only – who may not share that preference. The cosmetic outcome of circumcision is hideously ugly to me. I wouldn’t choose it for myself if I still had my choice. I am not the only one, since not all men are willing to be circumcised. The author’s opinion or statistics on female preferences about a male’s normal body are irrelevant until and unless the individual decides he wants himself circumcised.

Unsurprisingly, the authors never discuss male preference in the Ethics section. (More on that later.) The title of this post is the closest they get to mentioning the possibility. They mistakenly use that sentiment to reach the conclusion that infants should be circumcised. They endorse the view that if you can’t convince someone, promoting its imposition on them is somehow defensible. It isn’t.