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A Surgical Strike of Omission

According to his bio at the Council on Foreign Relations, Michael Gerson's areas of expertise are:

Democracy promotion; human rights issues; health and disease; religion and politics.

Not so much, based on his recent essay in the Washington Post, "A Surgical Strike Against AIDS". After a silly attempt at humor, warning about use of the word penis, he opens:

Circumcision is an, ahem, uncomfortable topic. The traditional Jewish bris calls this medical procedure a sign of blessing on the newcomer. Ten out of 10 male infants seem to disagree.

Right, ten out of ten male infants disagree. I think we should be able to agree on that. So far, so good, but let's keep that in mind as we look out for Mr. Gerson's alleged human rights expertise. (You already know what will be missing, don't you?)

Continuing:

During World War II, American soldiers were often circumcised to prevent the spread of sexually transmitted diseases (STDs) -- another hidden sacrifice of the Greatest Generation. From the 1950s to the mid-1970s, the circumcision of American newborn boys became increasingly common.

And we're off to the obvious conclusion. I'll make an assumption and temporarily accept that this version of history is correct, that American soldiers chose circumcision for themselves to prevent STDs, let me ask a reasonable question: how is it a "sacrifice" to society for soldiers to choose genital cutting to make unsafe sex "safer"? That sounds fairly selfish to me. And how does this logically morph into circumcising infants, which constitutes the next sentence in Gerson's essay? There should be an analysis of human rights offered between those two statements. There isn't. I wonder why.

Next:

But suddenly Uncle Irving seems pretty wise. Studies in Uganda, Kenya and South Africa indicate circumcision halves the risk of adult males contracting HIV through heterosexual intercourse. An author of one of those studies, Robert Bailey of the University of Illinois at Chicago, told me, "There is nothing else currently out there in public health or HIV prevention with protection results this compelling." Studies are ongoing to see if male circumcision protects women from transmission -- researchers suspect it might but are waiting for the evidence. The benefit for men, however, is increasingly undeniable.

Quaint, worthless reference to Uncle Irving aside, I'm calling bullshit. Condoms offer far more protection from HIV than circumcision could ever hope to achieve. I don't need to deny anything about circumcision to know this. Any scientist who claims otherwise is an idiot and unworthy of conducting genital cutting studies on human beings.

After a quick bit in which Mr. Gerson presents scientific speculation as fact¹, without naming Langerhans cells or paying lip service to contradictory evidence, Mr. Gerson continues:

... Massive infection rates seem to be associated with uncircumcised males, ulcerative STDs and having many concurrent sexual partners. Researchers hope that broader circumcision will remove a contributor to this deadly cycle.

Don't get distracted by the wrong parts of those sentences. Mr. Gerson expects you to focus primarily on one part, "uncircumcised males". But that's not useful to the eventual decision on whether circumcision is "good", or, more importantly, if it should be imposed on infant males. The two key parts here are "massive infection rates" and "concurrent sexual partners", which seems to me a clumsy way of saying unprotected sex (with HIV-infected partners). While it's clear that public health officials are looking for the cumulative effect of mass circumcision, I challenge anyone to argue that the decision to undergo genital cutting shouldn't be on an individual² basis. If we dismiss the notion of the individual, we eventually end at mandatory circumcision. That is simply unacceptable.

It should be clear to everyone that the real issue with (female-to-male) HIV transmission is the inevitable consequence of unprotected sex with HIV-positive partners. Circumcision will not prevent that. It may delay it, but infection will occur eventually. We already know that condoms and other safe sex practices are far more effective than circumcision, but it's worth emphasizing something useful from the studies in Africa. I hadn't thought to analyze the data this way, but Justin Jackson at This Week in Science offers a critical clarification of the data (discussion starts at 13 min. 30 sec mark). Basically, he highlights that the difference in HIV rates among the circumcised and intact males in the study was small, and even for the intact men, the overall HIV infection rate for the group was only 3.4%. The infection rate in the general population of Kenya is greater than 6%. The undiscussed reality of this study is that education generated a far greater reduction in the infection rate in both groups than circumcision created. When are we going to discuss that? (As he points out in the show, we must also consider the difference in education the two groups may have received, whether intentional or unintentional.)

Back to Mr. Gerson. After discussing cultural concerns about circumcision, he writes:

There are also practical obstacles. Like any operation, circumcision presents a risk of infection. Much of Africa lacks the equipment and personnel to perform the procedure on a large scale. But similar arguments were made against the possibility of AIDS treatment. A concerted American and international commitment proved that pessimism to be unjustified.

Like any operation, circumcision also presents a risk of complications. This gets ignored. Health expertise? If applied to non-consenting infants, human rights expertise?

Mr. Gerson is right that much of Africa lacks the equipment and personnel to perform mass circumcisions safely and effectively. Still, the recommendation is now out, with the accompanying hysteria. Circumcision has begun, whether countries are ready or not. That's quite irresponsible. But don't worry:

As circumcision scales up, the reductions in overall infection rates will be gradual. But the implications for the individual man in Africa are dramatic. A $40 or $50 procedure can cut his risk of HIV infection in half. Giving him that option is a matter of moral urgency.

How many condoms and educational materials would those $40 or $50 outlays fund? Also, note how Mr. Gerson mixes the mass action needed to generate a noticeable reduction with the individual action of a male. Stating that individuals have "that option" seems to indicate an appreciation for liberty with his utilitarianism, but don't accept such an assumption.

That begins with African governments. Both routine infant circumcision and adult circumcision must be considered, especially in the areas of highest infection.

Do those infants have "that option"? Remember, Mr. Gerson already admitted that ten out of ten infants disagree that circumcision is a sign of blessing. But Mr. Gerson advocates it anyway, going so far as to offer his nod to a cheap, dull cliché, calling circumcision "the kindest cut" . Human rights expert? In this area, his advocacy is makes him nothing more than an expert in violating human rights. That's the ultimate flaw in thinking that the terrible reality of HIV justifies radical action. I don't pretend that Mr. Gerson sees infant circumcision as radical, a viewpoint he shares with far too many Americans. But in calling for more European effort, he demonstrates his lack of concern for the ethical human rights aspect.

On that point, the crux of Mr. Gerson's error, I like this review of his article at Male Circumcision and HIV. This is at least as good as what I would've written, so I'll quote it here:

This swift acceptance of circumcision despite the obvious logical contradictions can only come from people accustomed to the practice of circumcision in their own culture. The reason why European nations are resistant to the implementation of this measure may just be that they have different moral values. Perhaps they can see more in an infant's objection to this surgery then [sic] simply an aversion to pain. Since European cultures have no interest in proving that circumcision has health benefits, they may still be sensitive to the rights of an infant to keep his genitals unaltered. Perhaps, since most European males have experienced life with a foreskin, they may find it delusional for a man to choose to have it cut off rather than put on a condom to prevent infection.

No interest in proving that circumcision has health benefits, they may still be sensitive to the rights of an infant to keep his genitals unaltered. Anyone reading these recent studies who doesn't at least question the application of those findings by anyone other than the male losing his foreskin should read that paragraph as many times as it takes to understand the ethical implications. Mr. Gerson included.

¹ Mr. Gerson also includes this poorly written argument:

A circumcised male is exposed to less HIV virus during sexual relations, and has less chance of being infected.

He should've said something like this:

A circumcised male has less (erogenous) mucous membrane, so he has fewer cells to become infected with HIV.

I don't pretend that he'd ever include erogenous, even though it's fact. But to state that a male is "exposed to less HIV virus" is silly. The same amount of HIV virus presumably remains in his partner, regardless of his surgical reduction. I don't think this was anything more than lazy writing. That doesn't excuse it.

² That individual basis should be left to the male who will lose his foreskin. Others argue that "individual" can include the male's parents. They are mistaken. But that is separate from the point I'm making here.

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