Words Like “Is” Have a Specific Meaning

Proponents of non-therapeutic infant circumcision are a curious group to me. Almost universally, I find them to be sincere in their belief that circumcision is beneficial, even though they are misguided for reasons based in objective facts. But I assume they’re well-intentioned rather than malicious. They don’t think circumcision harms. Even if I’m wrong about an individual’s approach and justifications, it’s both respectful and responsible to assume they’re well-intentioned rather than malicious. This is my standard.

University of Sydney Professor Brian Morris is a curious case within the curious group. I still think the above applies to him. I’m not quite sure why he makes the mistakes he does, though. He is prone to assign any criticism of non-therapeutic infant circumcision as fanatical lies. I believe he should’ve been educated in the course of his PhD work against making such disprovable declarations. Perhaps he was and missed its importance. I do not know.

That brings me to this otherwise irrelevant article on the question of whether or not Britain’s Prince George will be circumcised based on royal tradition. In the comments to the article, someone who appears to be Professor Morris commented on the article. To be fair, I can’t prove it’s Morris. The commenter logged in from a Facebook account, which includes what appear to be personal pictures of Professor Morris. The commenter’s writing appears similar to Professor Morris’ style. The evidence suggests a conclusion that the commenter is Professor Morris. But I work to avoid declaring what I can’t prove. I understand how declarative statements work and what they’re intended to do. Despite its clunkiness, I will attribute the comments to “the person claiming to be Professor Morris” rather than to “Professor Morris”.

Here’s the first comment on the story from the person claiming to be Professor Morris. It is why I link to the story.

Despite Dianna’s initial reluctance after her first baby was born, William and Harry were circumcised, in accordance with Royal tradition which Dianna acceded to.

I’ve seen no evidence supporting that claim. The article states that Princess Diana “reportedly would not allow her sons, William and Harry, to be circumcised.” I am, at best, marginally informed about royal gossip, so maybe there is evidence to support a claim that the consensus opinion is wrong. I don’t know. My point is that the “Princes William and Harry were circumcised” claim should have some support if the person claiming to be Professor Morris is willing to make it so definitive. When challenged, the person claiming to be Professor Morris responded:

William and Harry are almost certainly circumcised as is traditional in the British Royal family and upper classes. It is likely that Prince George is already as well, or soon will be. If there is genuine (‘undoctored’) photographic evidence to the contrary re William and Harry then please produce it. Otherwise what you say can be regarded as just another typical propaganda-based lie of circumcision opponents.

Now the person claiming to be Professor Morris says the princes were “almost certainly circumcised” rather than they “were circumcised”. Why make the original declarative statement? Or, why back off now? And notice how the person claiming to be Professor Morris demands photographic evidence that disproves his unsupported claim to demonstrate that the challenge isn’t “just another typical propaganda-based lie of circumcision opponents”.¹ The standard of fact employed here is only a one way requirement.

In response to a follow-up comment linking to ambiguous tabloid evidence, the person claiming to be Professor Morris responded (NSFW link at the original comment):

You have just proven to the world that Prince William IS circumcised.

Notice the return to a declarative statement. You may decide for yourself if the pictures are clear enough to warrant a declarative statement. You don’t have to bother. It isn’t important to my point because I’m interested in the “everything is pro-circumcision” argument offered in those comments by the person claiming to be Professor Morris.

The person claiming to be Professor Morris continued:

You haven’t examined the photographs adequately. The link of the fence gives the ILLUSION that it is the end of a foreskin, but a close look shows it isn’t, and you seem to be able to see the ridge of the glans.

The fence is an impediment, as is the distance of the photo. It’s a tabloid photo, not a documentary. Either theory could be defended on something in the photos. Just after saying it proves his point, the person claiming to be Professor Morris states that “you seem to be able to see the ridge of the glans”. Seeing the ridge of the glans proves nothing, especially in these unclear photos. A normal foreskin can be rolled back to expose the glans and possibly would be for urination. But to the person claiming to be Professor Morris, what you “seem to be able to see” is enough to justify a declarative statement. According to that approach, anything that supports circumcision is true, while anything that opposes circumcision is false. Contrary to the person claiming to be Professor Morris’ understanding, that is an actual example of propaganda, in the pejorative sense the comment quoted above intended.

¹ I am not a circumcision opponent. I oppose non-therapeutic genital-cutting (e.g. circumcision) on non-consenting patients, whatever their age or gender.

The New and Improved Circumcised Banana

Anyone who pays attention to circumcision in the news has seen some version of this silly attempt at “cute”, because “haha we’re talking about wieners, amirite”:

NY Magazine Hanna Rosin Circumcised Banana

Image Source¹

I’ve always disliked this image for the obvious reason that non-therapeutic child circumcision is neither cute nor funny. The image also irks me because it’s inaccurate. The reality would involve a banana that isn’t yet ripe. For example:

Circumcised Banana Is a Dumb Meme

The visual also requires a look at the changes to the banana as it “matures” after removing part of its protective covering:

Circumcised Banana After Time

What’s left of the banana changes, which is a fair representation of circumcision.

All of this is a ridiculous simplification because that’s what the original image is. I don’t expect my images to do any significant work for me. They only show how the original “circumcised” banana is a distraction. Non-therapeutic child circumcision is an ethical violation that deserves better than a superficial image that doesn’t tell the truth.

¹ I re-read Hanna Rosin’s drivel in “The Case Against the Case Against Circumcision”. I dismantled it in “Hanna Rosin Is Still Wrong On Circumcision, Revisited“. My primary point struck me again when re-reading the Rosin opinion piece. She cribbed straight from Edgar Schoen and Brian Morris, with no apparent research from a person who doesn’t vigorously advocate for circumcising healthy infants. She started with her conclusion and packed a bizarre subset of facts, omissions, and distortions into that neat box.

We Must Do Better

There’s a circumcision flowchart floating around that needs to be addressed. Here it is:


It fails from the start. The right first question is “Is there a medical problem with the foreskin?”, or something similar. That will get the circumcision decision process started.

“Do you have a penis?” is never a relevant question. It’s a sexist approach that fails to promote the critical, universal genital integrity rights involved. Fathers and mothers are equally capable of offering good and bad arguments on non-therapeutic child circumcision. We must address individuals, not generalizations. The latter leaves us making ineffective arguments to proponents who might be willing to change their mind to protect their son(s).

To put it in perspective, am I not allowed to denounce non-therapeutic female genital cutting because I don’t have labia or a clitoris? The idea is ridiculous. The human rights issue is first. We’re all capable of using our intellect and reason to understand genital integrity. Let’s use them and expect others to do the same.

If we start with awful premises, we interfere with our objective of protecting the bodies and rights of children. If we promote the idea that some people are inferior, they will tune us out when we state that all people should be treated equally. Please, stop promoting this flowchart. We can be better than this. We must be.

P.S. Shut up also needs to go.

Dr Limakatso Lebina’s Ridiculous Circumcision Euphemism

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

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

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

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

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

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

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

This, though, is absurd and offensive:

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

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

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

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

International Day of Zero Tolerance to FGM, 2013

Today is International Day of Zero Tolerance to Female Genital Mutilation. The WHO statement on this is lacking, which I don’t find surprising. (emphasis added)

The International Day of Zero Tolerance to Female Genital Mutilation is observed each year to raise awareness about this practice. Female genital mutilation of any type has been recognized as a harmful practice and violation of the human rights of girls and women. WHO is committed to the elimination of female genital mutilation within a generation and is focusing on advocacy, research and guidance for health professionals and health systems.

Female genital mutilation (FGM) refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons. Female genital mutilation has no known health benefits. On the contrary, it is associated with a series of short and long-term risks to both physical, mental and sexual health and well-being.

FGM is affecting about 140 million girls and women, and more than 3 million girls are at risk every year. A special focus for WHO this year, is the troubling trend of health-care providers increasingly being the ones performing female genital mutilation, and thereby contributing to legitimize and maintain the practice.

Today, I’m not going to discuss the comparison to male circumcision beyond the one inherent in this sentence. I am going to use WHO’s approach to male circumcision to compare why its last sentence shouldn’t be a surprise.

Stating that FGM has no known health benefits works from the premise that the possibility of benefits could justify FGM. No benefit could justify forced FGC (i.e. mutilation). The human rights principle is superior. WHO should state that as its foundation, and be consistent and repetitive. In reminding readers about this lack of benefits, WHO almost apologizes for being against FGM. The absence of benefits is not why this shouldn’t be done.

Think back to when the AAP issued a revised policy statement on FGC, later retracted. As I wrote here and here, I didn’t/don’t think it said what people read into it. But the reaction was universal and swift. On the idea that permitting limited forms of genital cutting could prevent greater harm to females, activists stood on the absolute principle. Whether or not this makes sense is a worthwhile discussion. (My posts linked above set out my thoughts on the issue. The principle still matters more.) Regardless, that incident demonstrates that activists would never excuse FGC/M if benefits were proposed or found. Can anyone imagine a scenario where any scientific committee allowed research into possible benefits? For those inclined to accept possible benefits as a justification, everyone else must discourage this thinking. Lazy statements that lack the courage to defends what is morally and ethically correct fail that goal.

WHO’s approach, which informs its stance on male circumcision, enables the predictable problems described in the last sentence. Because the organization refuses to stand for principle where courage is necessary, it creates the conflict of legitimizing genital cutting through “medical” male circumcision programs. I know of no populations that cut females that don’t also cut males. So, WHO drives campaigns to legitimize genital cutting while driving campaigns to delegitimize genital cutting. The flaw is obvious. The principle and consistency matter.

The Case Against “The Case Against Intactivism”

If you’ve read my work here (or on Twitter) for any length of time, you know that I don’t agree (e.g.) with every tactic used to argue for genital integrity. I’m not arrogant enough to assume I’m always correct, but my experience has to inform the means I endorse in pursuit of the necessary, noble goal. Where I think we’re making mistakes, particularly predictably ineffective mistakes, I speak out. I know enough people within the genital integrity movement to know that the principled, decent strategy is the most common.

That said, I’m not willing to paint broadly based on the actions of individuals. This can be either good or bad actions. One person expressing an idiotic excuse for circumcision do not mean everyone who shares a characteristic would defend that excuse. I do this because it’s fair and because I do not want this approach applied to me. It will always be possible to find genital integrity activists who engage in inexcusable behavior, such as anti-Semitism. I can make my case without that, as can most activists. Principles and tactics are associated, but the former exists apart from the latter.

This is why the website The Case Against Intactivism frustrates me so greatly. It is run by blogger “paper0airplane”, who is against routine infant circumcision while lumping any bad behavior by those opposed to circumcision into the “intactivism” category. This is wrong. For example, I spoke out when issue #2 of “Foreskin Man” appeared, long before it made news during the San Francisco ballot initiative in mid-2011. I was not alone. Should we all be blamed for this comic book, or are individual – sometimes egregious – mistakes inevitable in any decentralized movement? The answer is obviously the latter, but paper0airplane consistently writes as if it’s the former. That is what I wish to reject here.

In July paper0airplane posted this:

… My opinion also hasn’t changed. I do not circumcise, I don’t think circumcision is necessary. I also do not approve of the tactics used by intactivists, and were they to change those tactics, I would support them wholeheartedly. Much like the rabid pro-life crowd, intactivists generally resort to appeals to emotion, twisting of facts, offering up studies (that they haven’t even read) claiming they say one thing, when in fact they do not (relying, instead, on the fact that many will not actually read the study, simply providing one counts as support of their argument), sometimes outright lying. That includes setting up studies in such a way as to pre-determine the outcome. These are things that I disagree with, and will continue to disagree with. Since most intactivists, instead of actually reading my site objectively, believe that I am actually pro-circumcision and that my site advocates for circumcision, I’m attacked quite often. …

People who can be classified as intactivists cannot be neatly stuffed into a box labeled “Endorses These Tactics”. I am an intactivist, although what I wrote in 2006 still holds. The term intactivist is cute and descriptive, but because it’s cute, I do not like it. It does little more than give reporters an excuse to fill in stories with details at which typical readers will roll their eyes. That’s not helpful. The term has gained wider acceptance, but it’s still treated in much the same way in many places. And paper0airplane uses it as a convenient stereotype.

So, from that July post, in order:

  • Generally suggests stereotyping. That should be a signal that the critique is shaky. Not necessarily flawed, but evidence is required and should be drawn from and applied to the person(s) using the criticized tactic.
  • Appeals to emotion as a tactic is the least effective approach. Those who use it exclusively need to expand their repertoire. But its use, even exclusively by some, says nothing about intactivism as a whole.
  • I do not twist facts. Grinding this axe with a blunt dismissal of all rather than against the few who deserve it impedes my efforts. If paper0airplane insists on grouping everyone together, prove that I’m the hack caricature with examples. Otherwise, I’m left to assume that paper0airplane is a lazy thinker and writer. (The body of work that assumes any intactivist is all intactivists is evidence of this.)
  • I do not defend studies I know to be flawed. I’ve long held that the “estimated number of deaths” study is flawed¹. Conversely, I’ve also demonstrated that the “circumcision makes no difference to sexual sensitivity/satisfaction” studies are flawed. Should this count as an argument against all proponents of child circumcision or just those who fallaciously treat this issue as settled science based on these flawed studies? There are proponents who are very much lying propagandists. There are also proponents who are sincere and honest but insufficiently informed. I prefer to deal with who is in front of me rather than the worst of everyone I’ve ever encountered.
  • I’ve read enough to know that paper0airplane is opposed to routine infant circumcision. I also know that paper0airplane defends ritual circumcision. I disagree with this because the arguments against non-therapeutic circumcision, both ethical and scientific, apply to males born to religious parents. I do not wish to imply that change will be easy, only that change is necessary, as various reforms throughout history have been necessary. We are not at the pinnacle of balancing religion and rights. (More on this in another post.)

Going back to paper0airplane’s first post, this:

There are many many very reasonable people that label themselves intactivist. They’re nice people are are just as interested in the truth as you or I. Unfortunately, the loudmouths at the front are doing all the damage. They color public perception of what intactivism is. I think we can greatly reduce the number of circumcisions without being total A-Holes or alienating all our circumcising friends and family. Without being bullies. Because that’s what intactivists are represented by. Bullys. To the reasonable people that label themselves intactivist, I beg you! Find another way to label yourself! People will be more likely to listen if you don’t have to carry the intactivist baggage around.

This paragraph demonstrates my point. There are intactivists who use problematic and/or unethical tactics. Again, this is inevitable in any decentralized movement, just as one can easily find examples of the same among circumcision proponents. It’s possible to challenge, refute, and/or discredit “the loudmouths” without dismissing everyone by stereotyping on the behavior of a subset. I wish paper0airplane would make that effort instead of indiscriminately smearing good and bad activists as the same.

¹ While this study is not something I trust or cite, the number of deaths from non-therapeutic child circumcision is objectively non-zero. That is a fact. How many deaths from non-therapeutic genital cutting on a non-consenting minor do we need before we can demonstrate the ethical case against prophylactic child circumcision? The mere risk of one is enough, but one death is certainly too many. I suspect paper0airplane agrees, although that makes the accompanying defense of religious circumcision of children indefensible. Ritual circumcision of minors is no less an affront to human rights than cultural circumcision.

Adult Circumcision Healing Time

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

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

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

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

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

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

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

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

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

Joya Banerjee Misunderstands Opposition to Circumcision

Amazon.com reviews of Tinderbox: How the West Sparked the AIDS Epidemic and How the World Can Finally Overcome It, by Craig Timberg and Daniel Halperin, PhD, are the subject of a flawed essay by Joya Banerjee, titled “How an anti-circumcision fringe group waged an ideological attack against AIDS scholarship”. I doubt Ms. Banerjee wrote the headline, although it doesn’t much matter because she ues the same silly accusation in her article. After an introduction describing Tinderbox, she writes:

One of the preventive measures discussed in the book, male circumcision, has become an unexpected source of controversy. Anti-circumcision activists have hijacked Amazon.com’s “peer review” comments section, which allows readers to vote on which book reviews are helpful. This system has morphed into a vicious game of character assassination by conspiracy theorists who reject decades’ worth of scientific evidence, showing how easy it is for a concerted crusade to squelch good science.

My first response is to ask if Ms. Banerjee has ever been on the Internet before researching this piece. I mean that only partially in jest. This is how every comments section works, with few exceptions. The primary focus for blame here is probably in the design of Amazon’s peer review system, or at least in anyone placing any significant value on its worth in 2012 as the criterion for buying a book with a controversial topic.

She seems to understand this later in her article, which makes her unfocused back-and-forth attack on opposition to circumcision feel more like an agenda than a critique.

Where does all of this leave us? Two diligent and dedicated authors spent years researching the origin, spread, and potential prevention of AIDS in Africa. Two minutes and a few clicks were all that was required for a passionate extremist group to obfuscate and delegitimize their findings in front of one of their most important and public audiences. Having failed to prove their beliefs through scientific evidence, the intactivists decided to have circumcision, and this entire book, judged in the court of public opinion. Unfortunately for the public, this jury was rigged.

If all it takes is “two minutes and a few clicks”, that’s a flawed system, however inappropriate the action motivation’s may be.

She’s ignorantly inflammatory in her article because she does not appear to understand opposition to circumcision. It is not “extremist” to argue that potential benefits learned through adult volunteers do not negate concern for the ethics of applying that science to healthy, non-consenting individuals (i.e. minors). For some reason she never addresses this aspect of the debate. If she were interested enough to become informed, she could’ve challenged this behavior without misstating the facts about opposition to circumcision.

That said, there is a legitimate problem with this strategy. It’s inappropriate. We can do better. The full set of facts are on our side, and we should always act like it.

But, as problematic as this is, it isn’t as widespread as she declares with her bizarre, broad attack. Most who are against non-therapeutic child circumcision do not engage in this behavior or condone it from those who do. The title states that an “anti-circumcision fringe group” participated in this without naming any group. The group is somehow all “intactivists”. That’s irresponsible, bordering on the same type of unfair maligning she criticizes. She writes later in her article:

Although male circumcision occupies less than 10 percent of the book’s pages, it was enough to spark outrage among a tiny but passionately vocal fringe group, many of whom call themselves “intactivists.” They argue that the procedure is a grave human rights violation and are lobbying to ban the procedure in many countries.

Let me be clear: I do not support what happened on the Amazon page for Tinderbox. I didn’t participate. I don’t recall seeing anything resembling an attempt at an organized tactic. I recognize a couple names among those attached to 1-star reviews, and at least one name attached to a 5-star review, but that’s it. The correct way to state the facts here is that a small group of individuals have done this. It is incorrect, and defies common sense, to suggest that those who engaged in this constitute the entire group of people who oppose circumcision (of healthy children), as Ms. Banerjee’s sloppy accusation does.

Look at the numbers, which are no doubt now influenced further (in both directions) by Ms. Banerjee’s article. Consider this sample of the helpful ratings for one star reviews:

  • 91 of 232
  • 83 of 215
  • 81 of 212
  • 124 of 342
  • 76 of 277
  • 52 of 221
  • 33 of 197

Now consider this sample of the helpful ratings for five star reviews:

  • 114 of 129
  • 104 of 133
  • 111 of 151
  • 131 of 186
  • 73 of 135
  • 76 of 165
  • 101 of 153

They look similar¹, right? That’s not to minimize or dismiss (or legitimize) the gaming of the system. And voting down many of the 1-star reviews is probably appropriate. But it can work both ways. Amazon’s review system allows those who support the book to vote down a 1-star review on the basis of it being a 1-star review, without regard for its content. One seems more likely than the other, of course. Reasonable analysis and criticism must still start with the system, not its users. Where the users are wrong, the problem should be identified without hyperbole.

That last rating is also interesting because it’s the rating on the review left by Ms. Banerjee in June.

It’s really too bad that the reviews here have been taken over by an ideological group that shuns science and hard fact. This group has mobilized hundreds of people to write bad reviews and then rate their friend’s bad reviews as helpful.

The reviews (by people who obviously haven’t read the book) are really about their opposition to male circumcision, not about the content of the book at all. Which is pretty nonsensical, seeing as how the majority of legitimate public health institutions (including the World Health Organization and UNAIDS) have accepted that voluntary medical male circumcision prevents HIV by over 60%, and long term data shows it protects by 76%! That’s better than even the flu vaccine- so it’s surprising that these ideological quacks would rather let Africans die from a preventable disease than admit they don’t understand science.

Anyway, READ THE BOOK! There were (sic) always be quacks and naysayers out there (akin to those who still oppose the measles vaccine because they think it causes autism). The racist attacks on the author in these reviews do nothing to bolster their credibility!

I haven’t rated Tinderbox because I haven’t read it. I’ve skimmed it to get a feel for its treatment of circumcision. I have an unfavorable opinion about it based on that, but skimming isn’t enough to rate it.

She has read it. That doesn’t excuse that she engaged in nonsense in her review, as she also does now in her current article. It’s odd to suggest that “hundreds” of people are rating the book down when the number that could be attributed to opponents is obviously under 100. Exactly one 5-star review has more than 100 “unhelpful” ratings, and that one belongs to Professor Brian Morris, who engaged in the same sort of unhelpful ad hominem evidenced in Ms. Banerjee’s article. The math doesn’t add up to this being widespread among all intactivists, unless she honestly believes opposition to circumcision consists of fewer than one hundred people. The population who would do this probably is that small, but she painted opposition with the broadest brush possible, as she inexcusably does in her current Slate article.

It’s also silly to assume one has to shun science and hard fact to oppose non-therapeutic child circumcision. I don’t shun either science or hard fact. My position is that there are probably flaws in the methodology, but I don’t worry about them in my position because the correct position starts with present health and the ethics involved in consent. I assume every potential benefit is real, including reduced female-to-male HIV transmission in high-risk populations with low circumcision rates. But I am not a utilitarian who ignores individual rights, including the rights to bodily integrity/autonomy and self-determination. The right to be free from unwanted – and critically in this case, unnecessary – harm supersedes every potential benefit until the individual can weigh in with his personal preference on which he values more, the benefits or his foreskin. Where public policy or Tinderbox limits itself to voluntary, adult circumcision, I have no issues. The former rarely does, to its great discredit. The latter appears to follow the same pattern. For example, in Note 18 on page 352, Timberg and Halperin write:

… There has also been some confusion caused by mistaken comparisons with “female genital mutilation,” which is a very different type of procedure and can have serious negative medical consequences. …

This ignores the science and hard facts of male circumcision. Non-therapeutic genital cutting on a non-consenting individual is unethical whether it’s forced on a girl or a boy. Gender doesn’t matter here because all people, including male minors, possess the same basic human rights equally. That’s the ethical principle being ignored. That must stop.

Timberg and Halperin mistakenly imply that male circumcision is innocuous. All non-therapeutic genital surgeries have negative medical consequences for the individual that he or she may not want. (e.g. loss of foreskin, severed nerve endings, damage to/loss of frenulum) And some number of males have serious negative medical consequences, including partial or full amputation, as well as death. Perhaps they discuss this in the book. From my review of the indexed circumcision segments, I’m not convinced they take this into account. (During my prior reviews of Halperin’s work, most notably in this two part series on an awful paper to which he attached his name, I’ve seen no evidence that he assigns any weight to these facts.)

Continuing with Note 18 on page 352:

… Further confusing the issue of male circumcision are the protests of a small but vocal community of activists who often call themselves “intactivists” because of their belief that the male genitalia should remain entirely intact. This constituency has launched aggressive campaigns, including one that resulted in getting an initiative on the ballot in San Francisco to ban the performance of any circumcisions on minors in the city. California officials later ruled that cities had no authority over medical proceduress (sic). …

Neither I nor anyone I know believes that the male genitalia should remain entirely intact. That’s too simplistic and unconcerned with hard fact. I believe my gentials should have remained intact because I was healthy and my foreskin belonged to me. I believe every other male child’s healthy penis and foreskin should also remain intact until he may choose for himself, even if he ultimately chooses circumcision. The issue is bodily integrity and autonomy, not opposition to circumcision full stop. The San Francisco ballot initiative would’ve prohibited the performance of any circumcision on healthy, non-consenting minors in the city, not “any circumcisions on minors”. Omitting key words incorrectly frames the discussion and dismisses valid ethical (and scientific) concerns.

It’s also indefensible to engage in ad hominem (i.e. “ideological quacks” who “would rather let Africans die from a preventable disease than admit they don’t understand science”), as Ms. Banerjee does, without understanding the necessary qualifiers. Personally, I think everyone should use condoms because they prevent the transmission of HIV. If the adult male is so inclined, he may also volunteer to undergo circumcision. I don’t want anyone to die from HIV, but I don’t want anyone’s rights violated in a condescending good faith effort to force on him what someone else thinks he should want. If Ms. Banerjee wants to limit the discussion to voluntary adult male circumcision, that’s fine. She fails to explicitly limit the application of the science to the bodies of adult volunteers. From what I’ve read of Tinderbox, Timberg and Halperin fail to do so, as well. They should all recognize that they’re ignoring the ethical distinction between voluntary adult circumcision and non-therapeutic child circumcision.

Since this is indirectly a critique of Tinderbox, consider another footnote, note 18 on page 385.

… Meanwhile, some critics have suggested that male circumcision is similar to “female genital mutilation’ because it allegedly also reduces sexual functioning and pleasure. Unlike male circumcision, however, these practices-particularly the most extreme forms such as infibulation-can pose significant health risks for women. …

They’re repeating their error, treating male circumcision as if it carries an irrelevant risk of serious complications. But circumcision also changes the form of the penis, which changes the function. The mechanics are different. Maybe that’s better, maybe it isn’t. It’s unique to the individual, contrary to the majoritarian argument they’re about to make.

… In the rigorous studies that have investigated male circumcision’s effect on sexual pleasure, (115-28) nearly all men and their female partners report that after men become circumcised sexual pleasure is the same or enhanced, for both partners. During the 2005-2006 Swaziland pilot circumcision program mentioned in chapter 26, many women began saying that after getting circumcised their partners could have sex longer before reaching orgasm. Some of the clinic nurses reported that women would use metaphors such as, “He used to go from here [Mbabane] to Manzini [a city half an hour’s drive away], now he can go all the way to the border.”

Source 123, “Sensation and sexual arousal in circumcised and uncircumcised men”, states:

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

They (unintentionally?) demonstrate as much in their footnote, if only they were interested in the issue. The conclusion is that (voluntary, adult) circumcision doesn’t damage sexual pleasure because it is the same or enhanced for nearly all men and their female partners. So? This dismisses the diminished sexual pleasure for those outside the “nearly all” group. Those individuals matter, and no one should expect them to be mollified because another male is happy with his circumcision.

This approach is also based on “heads I win, tails you lose”. Circumcision is the same or better, and men can have sex longer. What logical reason can we think of that might explain lasting longer? Maybe this is good, but sexual pleasure involves a degree of individual preference. Not all males (or females) will want or need sex to last longer to enjoy it to the maximum extent for themselves.

Ms. Banerjee endorses this flawed argument in her article:

Although tens of thousands of men who were circumcised as adults and were studied in several large-scale clinical trials (and in a Slate series) reported no loss—and in many cases an increase—in sexual pleasure and function, the intactivists claim that male circumcision is equivalent to female genital mutilation, a practice whose purpose is to constrain a woman’s sexuality and impair sexual function. In one of its worst forms, a pre-teen girl’s clitoris and entire external genitalia are cut, scraped, or burned out, which can cause severe pain, infection, life-long incontinence, obstructed labor and delivery, and even death. To be truly equivalent, one would have to cut off a man’s entire penis in order to produce the same effect, rather than a small flap of skin.

First, that Slate series was ridiculous. I refuted it here and here.

Second, the possibility that one person might not like being circumcised as a healthy child exposes the ethical problem that she fails to address. Male circumcision involves control, and can be intended to directly impair sexual function. (It definitively alters sexual function.) Most forms of FGM result in far more harm than a typical circumcision, but civil law recognizes no level of acceptable harm from non-therapeutic female genital cutting, including forms less harmful than male circumcision. One does not have to remove the entire penis to produce the same effect that is legally prohibited for female minors. Male circumcision is not acceptable because FGM is usually worse. Even if the foreskin should be viewed as a “small flap of skin”, it is the male’s small flap of skin. Self-ownership rights do not disappear because possible benefits exist from a non-therapeutic surgical intervention.

Where she challenges the appropriateness of the comments attached to Tinderbox’s Amazon page, Ms. Banerjee is correct. Where she expands that into an indictment of any position against circumcision, she stumbles. There is more to the application of science to healthy individuals, whether adults or minors, than just a limited subset of science and hard fact. No male’s healthy body is a platform for expressing another’s personal preferences and fears, whether those of parents or technocratic public health officials.

¹ Sampled on September 26, 2012, except for the rating on Ms. Banerjee’s review. I updated that today because I kept the link.

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.

Revised Chart – AAP and Declining Circumcision Rates

In the AAP’s technical report supporting its revised policy statement on non-therapeutic male child circumcision, there is a graph depicting the recent trend in circumcision rates, as shown in three studies. The graph is on page 759. Here it is:

As Hugh notes¹ in his annotated version (pdf):

This chart suppresses 100%, making a near 50:50 split look like a large majority.

I edited the original graph to add the missing 30%. (I copied the the bars covering thirty percent and added them above the seventy percent marker.) It provides a different perspective on the current rate.

The difference isn’t huge, and is hardly the most compelling point against the AAP statement. (Neither is the missing 71-100% above.) But it’s difficult to accept that the space saved by stopping at 70% is an acceptable trade-off for the flawed perspective the original chart could create.

¹ As he also points out, the chart begins in 1999. This is not necessarily an egregious decision because they’re relying on studies that look at that time period. Data for the years and decades prior to this is available (pdf), of course, and shows a larger decline in the newborn circumcision rate over the last few decades.