Odd AAP Advice on Penile Development and Care

Adding to my post on ethics, I want to continue with the recommendations from the technical report on non-therapeutic male child circumcision issued by the AAP Task Force:

  • Parents are entitled to factually correct, nonbiased information about circumcision that should be provided before conception and early in pregnancy, when parents are most likely to be weighing the option of circumcision of a male child.
  • Parents of newborn boys should be instructed in the care of the penis, regardless of whether the newborn has been circumcised or not.

Notice the past tense in the second point. Parents should be instructed in the care of the penis before they decide to circumcise. My anecdotal experience suggests some number of parents circumcise in part because they don’t understand how to care for a normal penis. However small this number probably is, if parents shouldn’t be ignorant, the AAP should recommend education before the decision, not after. Some parents may leave their son his choice if they’re educated in how simple and non-scary it is to care for a normal, intact penis.

It should also provide factually correct information. From “Care of the Circumcised Versus Uncircumcised (sic) Penis” (Pg. 763):

Parents of newborn boys should be instructed in the care of the penis at the time of discharge from the newborn hospital stay, regardless of whether they choose circumcision or not. The circumcised penis should be washed gently without any aggressive pulling back of the skin.24 The noncircumcised (sic) penis should be washed with soap and water. Most adhesions present at birth spontaneously resolve by age 2 to 4 months, and the foreskin should not be forcibly retracted. When these adhesions disappear physiologically (which occurs at an individual pace), the foreskin can be easily retracted, and the whole penis washed with soap and water.25

No, they should be instructed about care before discharge. Even if we ignore the obvious point that a circumcision would likely already have been performed by that point, are parents not responsible for any care for their son while in the hospital? Unless a hospital is doing it wrong, they don’t just keep the child until parents are discharged and then say “here you go”.

More importantly, that paragraph contains factually incorrect information. The Task Force states that most adhesions present at birth spontaneously resolve by age 2 to 4 months, which is ridiculous. It’s also unsupported by their source. From footnote 25, Caring for the uncircumcised penis: what parents (and you) need to know by Cynthia J. Camille, FNP, CPNP, Ramsay L. Kuo, MD, and John S. Wiener, MD:

Penile growth, along with intermittent erection, aids in the process that eventually completely separates the prepuce from the glans to form the preputial space (Figure 1). This process begins late in gestation and proceeds at varying rates during childhood; therefore, the age when the prepuce is completely retractable also varies.2,3 Complete retraction past the corona is possible in at least 90% of boys by 5 years of age. In contrast, some boys will not have complete separation of the prepuce circumferentially beyond the corona until accelerated penile growth occurs at puberty.

Even if “90% by age 5” is correct (some evidence at this link suggests it might be an overestimate), that differs significantly from “by age 2 to 4 months”. This is a recipe for incorrect diagnoses of phimosis and forced retraction, leading to unnecessary circumcision for non-existent medical necessity.

If we look at source 24, the AAP’s Caring For Your Son’s Penis, it states:

The Uncircumcised Penis

In the first few months, you should simply clean and bathe your baby’s uncircumcised penis with soap and water, like the rest of the diaper area. Initially, the foreskin is connected by tissue to the glans, or head, of the penis, so you shouldn’t try to retract it. No cleansing of the penis with cotton swabs or antiseptics is necessary, but you should watch your baby urinate occasionally to make sure that the hole in the foreskin is large enough to permit a normal stream. If the stream consistently is no more than a trickle, or if your baby seems to have some discomfort while urinating, consult your pediatrician.

The doctor will tell you when the foreskin has separated and can be retracted safely. This will not be for several months or years, and should never be forced; if you were to force the foreskin to retract before it is ready, you could cause painful bleeding and tears in the skin. After this separation occurs, retract the foreskin occasionally to gently cleanse the end of the penis underneath.

The Task Force provided no obvious evidence to support its “by age 2 to 4 months” claim. Either they didn’t correctly source the claim they made, or they’ve allowed at least one mistake to enter the document. Neither generates much confidence in the overall process.

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.

The New Marketing in Action

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

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

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

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

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

Relevant to this problem with marketing:

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

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

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

That didn’t answer the question.

AAP Task Force Member Douglas Diekama Maligns Circumcision Opponents

The Washington Post’s parenting blog has a new post, ‘Intactivists’ furious at new AAP circumcision policy, that contains a misdirection from Dr. Douglas Diekema. After quoting Ronald Goldman and a few commenters to an earlier post, this:

AAP officials expected such a reaction.

“For individuals who have decided that circumcision is wrong, no amount or quality of data will put these questions to rest,” Douglas Diekema, who served on the AAP task force that wrote the report, told me last week when I asked him about potential pushback.

Diekema implies that people who are against circumcision simply haven’t correctly considered the data, which means “reached his personal conclusion”. He implies that opponents have made a demonstrable error in judgment. This is nonsense. It’s consistent to accept every single piece of data the AAP considered, and to ignore the relevant information the AAP explicitly ignored in its consideration, yet reach the conclusion that non-therapeutic infant circumcision is unjustified medically (and ethically), contra the AAP’s biased and flawed statement. To quote Douglas Diekema himself:

… But it does have medical benefit. Not everyone would trade that foreskin for that medical benefit. …

No kidding. That’s the ethical issue, but it also shows that the benefits do not outweigh the risks for every individual. Diekema is engaging in propaganda, facilitated by The Washington Post. Both aspects of that are inexcusable.

I’ve sent an e-mail to the Washington Post blogger, Janice D’Arcy, asking for comment on Diekema’s problematic quote. I will update if I receive a response.

Brian D. Earp on the AAP’s Flawed Circumcision Policy Statement

If you read only one analysis on the AAP’s revised policy statement on infant circumcision, make it this fantastic deconstruction by Brian D. Earp. It’s almost too perfect to excerpt. This is a great sample, but his entire post is required reading.

Here they depart from their 1999 statement in asserting that (1) the benefits of the surgery definitively outweigh the risks and costs and (2) that it is therefore justifiable to perform the operation without the informed consent of the patient. This does not follow. In medical ethics, the risk/benefit rule was devised for therapeutic procedures aimed at treating an extant pathological condition, and for minor prophylactic interventions such as vaccination. It has no relevance to nonessential amputative surgery, especially when it involves the painful removal of healthy, functional erogenous tissue from the genitals, and when safer, more effective substitute strategies exist for achieving the same ends.

You may be surprised to learn that the word “condom” does not appear even once in the 28 page AAP report.

In making their risk/benefit calculations, then, the AAP simply leaves out a critical bulk of factors relevant to the equation, including the existence of a range of proven healthcare tools like condoms, vaccines (including an effective HPV vaccine), and antibiotics. If they had bothered to consider human rights and bodily integrity issues, the function of the foreskin, its value to the individual, and his possible wishes in later life, as well, their computations would quite plainly yield a very different answer.

Seriously, it’s worth the time. And share it far and wide.

The AAP Worsens Its Flawed Circumcision Position

A lot has already been said about the AAP’s revised policy statement on non-therapeutic circumcision on non-consenting male children.

More will be said today and beyond. Much of it will be uncritical regurgitations of the AAP’s revision by news organizations. There will also be analysis from those who recognize and highlight the glaring deficincies and oversights in the policy. I expect to contribute my own thoughts. For now, I’ll highlight one key aspect from my initial read-through before going into what I think is a more important consideration to this apparent-but-not-really temporary setback.

The short version of the statement ends with this (emphasis added):

Parents ultimately should decide whether circumcision is in the best interests of their male child. They will need to weigh medical information in the context of their own religious, ethical, and cultural beliefs and practices. The medical benefits alone may not outweigh these other considerations for individual families.

That’s so close to the ethical stance. Remove families and focus on the individual and it would be ethical¹.

The way the promoted portion of the new “finding” within the revised statement differs from this conclusion is the key takeaway to challenge the supposed change from the AAP, which is really more-or-less just an exercise in urging politicians to permit circumcision on Medicaid. Here, the AAP demonstrates that its evaluation of the net benefit, that possible benefits outweigh the risks, is subjective and determined only by individuals. This directly contradicts the supposed proof based on their review of research that the potential benefits outweigh the risks (and the costs – the direct harm in every case – that they ignore). We should repeatedly emphasize that as often as necessary.

My concern is that we’ll get stuck in this low-level, short-term portion of the larger debate. It’s clear from European medical associations and courts that the eventual destination is public policy against non-therapeutic circumcision. The AAP and American society, in general, are (inexcusably) behind. But both will get there. Activists for the rights of children can make that happen sooner than it otherwise might happen.

The key is that we must give people the opportunity to save face, to avoid digging in to protect their egos. The problem is their stance, not necessarily their character. It should be obvious to them that their stance is incorrect. It isn’t. To address that, do we want to express an irrelevant, limited sense of superiority or convince others that we’re correct because facts and ethics demonstrate the case we’re making? If we impugn their motives and/or character by choosing the former, we may extend the period during which this policy statement stands or encourage people who can be influenced either way to choose the inferior stance of the AAP.

Edit note: I changed “it’s” to “their stance” to avoid possible confusion.

¹ The existing societal view treats certain basic human rights – for boys only – as a buffet from which parents may pick and choose for their own reasons. This is the problem merely expressed within the AAP’s policy statement.

Flawed Circumcision Defense: Yair Rosenberg, Part 2

In response to the AAP’s pending release of its revised policy statement on non-therapeutic male child circumcision, Yair Rosenberg repeats the mistakes in his prior analysis. He perpetuates appeals to authority, omits relevant information, and ignores inconvenient facts. One might even say he’s being obscurantist.

This isn’t just an issue of religious freedom—it’s a basic question of public health. That’s because according to the National Institutes of Health and the World Health Organization, among others, circumcision is one of the global health community’s best HIV prevention techniques. As Eric Goosby, the U.S. AIDS coordinator, has said, “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.” To that end, anti-AIDS organizations are partnering to circumcise 20 million African men by 2015. …

Until now, the scientific consensus surrounding circumcision has driven policy in Africa, but not the United States. Today, that changes.

Individual humans make up “public health”. What is – and is not – acceptable to do to individual bodies in the name of public health is the question of ethics that Rosenberg, Goosby, the AAP, and every other circumcision advocate ignores. This is especially true because circumcision is not the least invasive or the most effective method available for reducing HIV (or any other) risk. It’s also still not particularly useful in contexts outside of parts of Africa. As I wrote in my prior post, the risk reduction is in female-to-male HIV transmission in high-risk populations. That isn’t compelling within the scope of the AAP’s focus. Context matters. Obscurantist journalists ignore that.

The importance of this [updated policy] cannot be overstated. …

It can be. Rosenberg’s post is proof.

… The AAP is a driving force behind health policy in America, and the experts involved in its new statement are already going on record in major media outlets to advocate that circumcision be covered on public health plans like Medicaid. The statement solidifies the scientific consensus behind the advisability of infant male circumcision (noting that complications are more likely to arise when the procedure is performed later in life) and places the traditional practice squarely within the realm of sound medical science.

This is only true if ethical considerations are not a part of sound medical science. It’s fine if Rosenberg or others do not wish for ethics to be applied to their own bodies. But not everyone shares that odd, limited view. Some of us appreciate the basic concept of human rights, including those of physical integrity and self-determination, and wish they had been applied to us. It’s too late for too many males, but there is never a bad time to stop violating human rights.

Also, the question of possible benefits and their applicability to any particular individual is separate from the public policy question of paying for non-therapeutic surgical interventions on non-consenting individuals. Non-therapeutic infant circumcision is an irresponsible use of funds in pursuit of subjective goals via unethical means. There is nothing good about it, regardless of how “prestigious” an organization promoting the idea is irrationally perceived to be. An organization that advocates violating human rights deserves no prestige.

This is not just good news for the United States, where obscurantist anti-circumcision groups have sought to completely ban this medically beneficial practice rather than allow families to choose whether to perform it. …

Rosenberg’s prior essay was obscurantist propaganda. Unlike his writing, I’ve acknowledged the arguments offered in favor of circumcision. I’ve explained why they’re inferior in the debate as it pertains to individuals. Mr. Rosenberg has not done the same. Instead, he offers condescending evasions:

… It’s also a powerful rebuttal to the flawed reasoning of the German court in Cologne, which ruled that circumcision generally constitutes “bodily harm,” yet made allowances for circumcisions performed for “medical reasons.” Thanks to the AAP, we can now state that all circumcisions are medically beneficial. …

The German court in Cologne ruled that non-therapeutic circumcision on non-consenting children violates their rights to physical integrity and self-determination. There is no flaw in that expression of basic human rights. The are the same rights that form the basis for prohibitions on FGC/M.

The court’s finding that circumcision constitutes bodily harm, no quotes, is consistent with permitting circumcision for medical need. The existence of a problem necessitates considering interventions. Ethically proxy consent will choose the least invasive, most effective solution. That is rarely circumcision when there is a need. But where it is necessary, the goal is an objective net benefit, that the surgery will remedy the problem. The outcome is presumed to outweigh the harm imposed to achieve it. The key is the outcome can be measured immediately and directly. Is the malady resolved?

With non-therapeutic circumcision, there is no objective net benefit because there is no malady. There is only objective harm for subjective benefits. The subjective benefits may not be valued or desired by the individual. In that case it’s objective harm to the individual for the subjective preferences of another. That is unethical. Because surgery on children involves proxy consent, medical need is required. The court was correct and consistent. The AAP is incorrect and encouraging unethical rights violations.

So, can we really state that all circumcisions are medically beneficial? Including the ones where the boy suffers a complication? If he loses his glans, is he still benefited? What about his entire penis? What about the thankfully rare instances where the boy loses his life? At least the benefits accrued over his short lifetime? Since all of these scenarios happen, even if we ignore my focus on individuals who suffer only the expected harm, isn’t it a bit obscurantist to state that all circumcisions are medically beneficial?

… If German courts continue to prosecute Jews and Muslims for practicing circumcision, then we will know that this animus is rooted not in science or fact, but in ignorance and prejudice.

I won’t say I expected his screed to end with something other than a preemptive ad hominem attack. It’s still pathetic.

Update: Walter Russell Mead uncritically endorses Rosenberg’s flawed post and makes a request:

Hopefully anti-circumcision zealots will take a deep breath and rethink their fevered stance on the issue. Beyond the fact that their bans impinge on the rights of Jews and Muslims to practice their religion as they see fit, they ought to consider that there is legitimate science pointing to the practice being beneficial to infant male health.

The only legitimate science involving infants is on UTIs, and possibly penile cancer. The former are uncommon in intact males in the first year (1%) and almost always easily treatable. The latter is more reasonably associated with other causes, with U.S. rates similar to those in mostly intact Europe. Everything else involves adult volunteers. The possibility of health benefits, or even religious benefits, does not render non-therapeutic circumcision on a child ethical.

No court in the United States endorses a right to practice one’s religion as members “see fit”. There are limits that may be imposed based on constitutional tests. Non-therapeutic child circumcision should fail that test because it is physical harm.

Infant Male Circumcision and Current Human Rights Disparities

Another focused post for a story on which I’ll have more to say.

In a study published Monday in the Archives of Pediatric and Adolescent Medicine, a team of economists and epidemiologists estimated that every circumcision not performed would lead to significant increases in lifetime medical expenses to treat sexually transmitted diseases and related cancers — increases that far surpass the costs associated with the procedure.

I strongly suspect the study is flawed because it makes estimates. I’ll withhold further comment until I know more. For now, there’s enough to discredit the embarrassingly incomplete approach used to justify the study and its estimates.

That sentiment [that Medicaid should cover non-therapeutic child circumcision] was echoed in an editorial accompanying the study. UCLA health economist Arleen Leibowitz wrote that by failing to require states to cover circumcision in Medicaid plans, the U.S. reinforces healthcare disparities.

“If we don’t give poor parents the opportunity to make this choice, we’re discriminating against their health in the future,” she said in an interview. “If something is better for health and saves money, why shouldn’t we do it? Or at least, why shouldn’t we allow parents the option to choose it?”

We shouldn’t do it or allow it because non-therapeutic genital cutting on a non-consenting child is unethical. Male circumcision on a healthy child violates his basic human rights to bodily integrity and self-determination. It is indefensible, even if it’s possibly “better” for his health in someone else’s subjective evaluation or because it saves money when individuals are considered statistics rather than human beings with their own rights and preferences.

The abstract makes it clear the study is speculative. Yet, we already have rights-based law for females without absurd exemptions we refuse to touch for males, so the idea that rights trump speculative benefits isn’t foreign. The ability to do something or to possibly achieve some population-level result without concern for the individuals involved cannot – must not – be viewed in a bubble that contains only the factors one is interested in (e.g. male circumcision is currently practiced, so it’s acceptable).

There are no doubt many non-therapeutic surgeries we could perform on children that might result in some decreased prevalence of disease x, y, or z. Infant mastectomies to remove breast bud tissue might reduce the risk of breast cancer. Shouldn’t we study that, at least, since it might reduce cancer? Reducing cancer is “good”, whatever the means, right? No one is foolish enough (yet?) to think such a thing, which highlights the flaw in thinking by those making excuses for circumcision, such as Ms. Leibowitz here. Society should stop ignoring the costs to the individual who must bear the outcome of the decision. Ignoring them is unacceptable. The ethics of circumcision are not divisible from any other basic human rights consideration or proper medical analysis based on therapeutic need, or lack thereof.

Finally, that non-poor families can afford to violate their children’s sons’ rights is not a reason to use taxpayer funds to let poor parents violate their children’s sons’ rights. That’s a political question rather than a medical question. It is inexcusable to sacrifice the bodies of male children (only!) because we’re too cowardly to honestly evaluate the mistake of non-therapeutic circumcision on non-consenting individuals. This is the same idiotic approach Dr. Edgar Schoen pushed in his 2005 propaganda book, “Ed Schoen, MD on Circumcision”. Somehow, not using public funds to violate a child’s body and rights is discrimination. It isn’t because circumcision is not a valid parental choice. UCLA health economist Arleen Leibowitz is wrong.

None of this is a surprise, based on the editorial by Ms. Leibowitz and Katherine Desmond, “Infant Male Circumcision and Future Health Disparities”. The first two sentences reveal so much.

The health benefits of male circumcision (MC) have been extensively documented in observational studies and by randomized controlled trials in Africa showing that MC reduces heterosexual transmission of human immunodeficiency virus (HIV) infection from women to men by 55% to 76% …

The trials showed that voluntary, adult male circumcision reduces female-to-male HIV transmission in high risk populations with a heterosexual epidemic and a low rate of circumcision among adult males. That’s quite different, since it doesn’t describe the United States. It also fails to describe the circumcision they’re advocating. Children are not adult volunteers. That’s the ethical flaw in their analysis.

… and provides significant protection against human papillomavirus infection. …

Gardasil is approved for girls and boys. Circumcision is unnecessary for this possible benefit, as it is for nearly every possible benefit.

… Male circumcision is negatively associated with prostate cancer in men and with cervical cancer in female partners of men infected with human papillomavirus.

Negatively associated. Correlation is not causation. The study’s authors acknowledged this when they stated that it was an observational study. “Negatively associated” is not sufficient.

The Marketing Changes Again

Hospital Male Circumcision has been sold with evolving euphemisms in an attempt to hide the ethical flaw in the associated public health policies. First, it was Voluntary Medical Male Circumcision, which never meant voluntary or even medical. The only requirement was a penis with a foreskin. Then it changed to Medical Male Circumcision. That involved 50% less pretense, while retaining 100% of the ethical omission. Now, it’s changed again:

Health facilities across the country have run out of supplies for Safe Male Circumcision kits, an HIV expert has said.

It’s better that they dropped medical, but replacing it with safe is little better. First, males will suffer complications beyond the guaranteed loss of the foreskin. Most of them will be minor. Some of them will be significant. Safe will be false.

It’s also possible the word’s meaning will be misconstrued.

The medical practice is intended to prevent HIV infection but it is not 100% safe, medical experts claim.

According to World Health Organisation and United Nations AIDS (UNAIDS) trials in Uganda, South Africa and Kenya have shown that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%.

I can’t fathom a scenario in which the public health officials intended safe to describe HIV after circumcision. Yet, that’s what this reporter took from it. That does not bode well. That’s a danger of propaganda. It’s inexcusable because there are lives at stake.

The premise of the article is worth addressing, too. They’ve run out of supplies. The article implies that they’re not circumcising while they lack supplies. That’s the right answer, of course, so I hope that’s what is happening. But I’m also concerned by the description of the kits as containing “reusable and disposable supplies”. Are they adhering to that distinction? And are the reusable supplies being sterilized properly?