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Because... HIV!

It's easy to talk about "public health" as if we're all in one giant collective, with the same needs and desires. But that's not true. We are each an individual, with specific, unique considerations. It is foolish to pretend that one approach is sufficient for everyone. It is offensive to behave as though the recipient of that one approach is irrelevant to whether or not it should be applied. Consider:

Public health officials [at the Centers for Disease Control and Prevention] are considering promoting routine circumcision for all baby boys born in the United States to reduce the spread of H.I.V., the virus that causes AIDS.

The article is little more than the latest 6th Grade Current Events drivel churned out from the New York Times' "Promote Infant Male Circumcision" template. Guess where the author/editor placed this paragraph in the story:

Circumcision is believed to protect men from infection with H.I.V. because ...

The paragraph demonstrating that scientists do not yet understand how circumcision is supposed to reduce the risk of female-to-male HIV transmission should probably appear early, before the committed sentiments from those wishing to transfer the findings on adult volunteers in Africa to infant non-volunteers in America. Yet, it's the last paragraph in the article. 916 words precede the significant fact that advocates do not yet know the relevant fact to support what they now wish to force on children.

Unsurprisingly, the word ethics appears nowhere in the article. The mere suggestion of potential benefits, despite the irrefutable fact that they are not needed and the high probability that they would not be desired, is enough to take pro-infant circumcision advocates seriously when the logic of basic human rights and medical ethics demands that we dismiss them from polite company. Instead, this passes for "serious":

But Dr. Peter Kilmarx, chief of epidemiology for the division of H.I.V./AIDS prevention at the C.D.C., said that any step that could thwart the spread of H.I.V. must be given serious consideration.

“We have a significant H.I.V. epidemic in this country, and we really need to look carefully at any potential intervention that could be another tool in the toolbox we use to address the epidemic,” Dr. Kilmarx said. “What we’ve heard from our consultants is that there would be a benefit for infants from infant circumcision, and that the benefits outweigh the risks.”

Does "any potential intervention" have any ethical limitation? Removing the boy's penis would surely solve the transmission problem. Is that acceptable?

I am, of course, being intentionally ludicrous. Removing a boy's penis is not what Dr. Kilmarx is suggesting. Yet, he is promoting a mentality that how he fears HIV and values prevention is the only acceptable approach. Therefore, any intervention he deems appropriate must be appropriate. Because... HIV!

It will not work, for several key reasons, all easily identifiable and critical to the process:

He and other experts acknowledged that although the clinical trials of circumcision in Africa had dramatic results, the effects of circumcision in the United States were likely to be more muted because the disease is less prevalent here, because it spreads through different routes and because the health systems are so disparate as to be incomparable.

There is little to no evidence that circumcision protects men who have sex with men from infection.

Another reason circumcision would have less of an impact in the United States is that some 79 percent of adult American men are already circumcised, public health officials say.

Add to that the reality that any infant male circumcised today to prevent reduce his (already low) risk of HIV will not be sexually active until approximately 2024 or beyond. When he is sexually active, he'll still need to wear a condom. Circumcision will have added nothing to his life as an HIV prevention. It's success, however limited it would be, depends upon the male behaving irresponsibly. An assumption that a boy will be irresponsible is not a valid justification for the surgical removal of a healthy, functioning body part.

Yet, that basic human right - the same right accepted and codified for female minors - is denied to male minors for nonsensical reasons:

The academy is revising its guidelines, however, and is likely to do away with the neutral tone in favor of a more encouraging policy stating that circumcision has health benefits even beyond H.I.V. prevention, like reducing urinary tract infections for baby boys, said Dr. Michael Brady, a consultant to the American Academy of Pediatrics.

He said the academy would probably stop short of recommending routine surgery, however. “We do have evidence to suggest there are health benefits, and families should be given an opportunity to know what they are,” he said. But, he said, the value of circumcision for H.I.V. protection in the United States is difficult to assess, adding, “Our biggest struggle is trying to figure out how to understand the true value for Americans.”

This is the coward's path¹. They won't recommend it, but they'll tell parents it's really wonderful and prevents all these scary things. They'll dismiss the risks and ethics involved, and they'll ignore the statistics in context. For UTIs, the statistics show that all males, circumcised and intact combined, face approximately a 1% risk of UTI in the first year of life. The majority of those UTIs are easily treated without circumcision. Those that are not are generally caused by anatomical abnormalities, not the presence of the normal foreskin. [ed. note: Links when I can find them. It's late.]

But none of that matters to those who believe that parents should decide what is best for their family regarding their son's foreskin. We don't extend this appalling idea that the family owns the foreskins of its sons to the genitals of its daughters. No, a female minor's genitals belong to her, regardless of the parents' opinions. That's critical in displaying the hypocrisy and cultural blinders because the advocates are only discussing opinion. They've established a perceived value to non-therapeutic male circumcision. They've endorsed that with the power of their titles to those parents who want to believe the same illogical conclusion. Because they value it, they can't conceive that the healthy child who will be surgically altered could possibly mind. He wants it, don't you know, because dad likes it and mom likes it and what if his classmates laugh at him or girls won't have sex with him? He needs to have less to be enough. And because... HIV! That he could conclude that non-therapeutic circumcision performed on him as an infant is mutilation is inconceivable. The person who believes that is allegedly the fringe lunatic who rejects the public health. Because... HIV!

To the CDC: My non-therapeutic circumcision as an infant was mutilation. My parents had no legitimate authority to request it. The doctor had no legitimate authority to perform it. I do not value circumcision for me. I never will, no matter how much your unethical experts tell me I should. I have never and will never need any HIV risk reduction because I do not engage in unsafe sex. Should I encounter any of the other medical maladies discussed in relation to circumcision, I will prefer the least-invasive effective treatment available. I believe in evidence-based medicine, particularly the simple-to-understand truth that healthy genitals are evidence that no surgical intervention is ethical on a child. Not even on the genitals of American boys.

¹ It is also why appeals to the authority of an organization like the AAP are unwise. They may present a (barely) acceptable tone today, but tomorrow is always a new day to be irrational.


THANK YOU for posting this! Your support and well-articulated arguments are so very much appreciated.

Hey Tony, some rough back of the napkin numbers for you:

According to avert.org approximately 56,000 Americans are infected with HIV each year. Overall, about three-quarters of those infected were men, approximately 42,000.

When examined by gender, [men only] approximately 62% were infected via male-to-male sexual contact, 18% were infected via IV drug use, and about 8% were infected via either IV drug use or male-to-male sexual contact. What remains is 12% which was thought to be contracted heterosexually, 11% is considered high-risk heterosexual contact while 1% must contain all other possible modes of transmission. According to Avert, the CDC defines high-risk sexual contact as:

"The "high-risk heterosexual contact" category comprises persons who report specific heterosexual contact with a person with, or at high risk for, HIV infection (e.g., an injecting drug user). This does not include adults and adolescents born in, or who had sex with someone born in, a country where heterosexual transmission was believed to be the main mode of HIV transmission, unless they meet the criteria stated in the previous sentence." See Avert.org link.

So of the 42,000 men infected about 4620 (give or take) were infected via high-risk heterosexual sex. Or about 5,040 if all heterosexual sex is considered. The US has a male population 15 - 64 of over 100,000,000, if 10% [Dave just posted a story at C&HIV which indicates this is actually 4%] of them are homosexual we are talking about 90,000,000 men. Given these figures, in any given year a man has about a 0.005% (1/20,000) chance of becoming HIV positive [via heterosexual sex both high and normal risk] (5000/90,000,000).

Over 50 years (15 - 65), the chances of turning up HIV positive would be 0.25% or (1/400) (0.005 * 50). These are exceedingly low numbers for an individual (overall) however, this is for those who fall with in the high-risk heterosexual category, which according to the CDC would include those whose partner are known to be HIV+, suspected to be HIV+, or are at high-risk otherwise (an IV drug user for example). We know that most people will not fall within this category and certainly not over the course of 50 years.

The truth is that this represents a ballpark upper bound which assumes that a man will be in the high-risk category his whole life. The real lifetime risk is probably much lower. The AFAO figured the overall risk for Australian men which I think is closer to the risk for US Men, and it's a whole order of magnitude lower than my figure which is really an upper bound. I mean few people are in the High-Risk hetero category and fewer still for 50 years.

BTW, Dave just posted a story about the results of a large study on gay HIV acquisition. Guess what, circumcision didn't help but that's OK forget the 70% of the Male HIV population go for those at least risk.

It is likely, actually highly likely that the real story behind CDC doing a turnabout based on vague paramenters is that there is an increased need for Embryonic Stem Cell Material, now that stem cell research has been given the green light. That would be infant foreskins. CDC changes their stance, a few well placed editorials invoking fear of HIV, and presto: more raw mateial.

Speaking of risk, a certain, non-zero, number of infant circumcisions are botched. Any estimates showing that the assumed lower risk from risky behaviour is offset by such mishaps?

Brainwave scans of infants show they are in shock for days, yes two or three days after circumcision. Ancedotal evidence correlates that countries with the highest rates of circumcision are also the most aggressive, warlike. Shock and Awe!

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