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The Facts, Although Interesting, Are Irrelevant

When I wrote about the American Academy of Pediatrics' revised policy statement on ritual genital cutting of female minors, I sensed some misunderstanding of what the policy says. Then the story hit the New York Times, among many outlets covering it, confirming what I suspected.

In a controversial change to a longstanding policy concerning the practice of female circumcision in some African and Asian cultures, the American Academy of Pediatrics is suggesting that American doctors be given permission to perform a ceremonial pinprick or “nick” on girls from these cultures if it would keep their families from sending them overseas for the full circumcision.

Saying that the AAP now supports female genital cutting grabs attention, but it's not an accurate summary of the policy statement. The AAP's conclusion:

The American Academy of Pediatrics:

  1. Opposes all forms of FGC that pose risks of physical or psychological harm.
  2. Encourages its members to become informed about FGC and its complications and to be able to recognize physical signs of FGC.
  3. Recommends that its members actively seek to dissuade families from carrying out harmful forms of FGC.
  4. Recommends that its members provide patients and their parents with compassionate education about the physical harms and psychological risks of FGC while remaining sensitive to the cultural and religious reasons that motivate parents to seek this procedure for their daughters.

I stand by my original interpretation that the AAP left itself room to appeal to both sides of the argument. It brought up a ritual 'nick' for ceremonial blood, but avoided anything more declarative than hinting that it should be discussed. But it did not endorse female genital mutilation, unless one defines genital mutilation as any blade-to-genitals. (If that's your definition, I agree from my rights-based perspective, but the same applies to male genital cutting.) If the goal is to reduce and eliminate harm to children, it's stupid to suggest that we factor anything other than harm from non-therapeutic genital cutting and sexist to suggest the victim's gender matters, somehow.

So, to be clear, I don't have much respect for the AAP, for multiple reasons. It's revised statement is cowardly. And I'm angry that the story has careened in a manner that requires me to defend an organization unable to reject non-therapeutic male circumcision, a practice it admits¹ is harmful. But here, with this statement, the AAP did not recommend that doctors perform female genital mutilation, nor did it initiate discussion of anything other than the least harmful forms of Type IV as a substitute for Types I, II, and III in a context where some form of genital cutting is likely.

To its credit the New York Times called the AAP:

A member of the academy’s bioethics committee, Dr. Lainie Friedman Ross, associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago, said the panel’s intent was to issue a “statement on safety in a culturally sensitive context.”

Dr. Friedman Ross said that the committee members “oppose all types of female genital cutting that impose risks or physical or psychological harm,” and consider the ritual nick “a last resort,” but that the nick is “supposed to be as benign as getting a girl’s ears pierced. It’s taking a pin and creating a drop of blood.”

I don't accept that ear piercing is benign, but for the purposes here, Dr. Friedman Ross shows that the AAP did not say what many now hysterically claim it said. The now-accepted misunderstanding of its revision is unfortunate because there's a relevant, necessary path for the discussion to take now that it's opened:

Dr. Friedman Ross said, “If you medicalize it and say it’s permissible, is there a possibility that some people will misunderstand it and go beyond a nick? Yes.”

But she said the risk that people denied the ceremonial procedure, usually on the clitoris, would opt for the more harmful one was much more dangerous.

I'd like to see research to back that claim, but for some (probably significant) percentage, I have no doubt she's correct. Unfortunately, the hysteria now present in the debate involves people who either have not read the revised policy statement or have poor reading comprehension skills, so we can't approach that topic. (Remember, too, that I wrote that I favor of zero tolerance on this if you wish to accuse me of anything for pursuing the discussion.)

Instead, we're left with people preening about an existing, incomplete (or inaccurate) narrative. The sentiment seems to be a determination to show that one cares about the issue in the correct way rather than figuring out how to minimize harm to children. I'm not saying that people who exhibit the former are uninterested in the latter, but they're inadvertently working against the legitimate goal.

Post Script: I'd planned to include examples from other sources. Since they generally raise issues that are tangential to my objective in this post, I will address them separately.

¹ The AAP exhibits its cowardice by admitting this indirectly. It engaged in obvious moral relativism as it acknowledged that male circumcision is more harmful than what it proposed we discuss and that causing harm violates the physician's "principle of nonmaleficence." But the proper conclusion that non-therapeutic male circumcision is harmful and should therefore be prohibited on male minors is unavoidable from the bioethics committee's statement on female genital cutting.

Comments

To respond to your footnote, Tony, the AAP do not state that male circumcision is more harmful than what is discussed. They state that it is more extensive: "However, the ritual nick suggested by some pediatricians is not physically harmful and is much less extensive than routine newborn male genital cutting."

I suppose one could argue that extensive procedures are automatically harmful, but it would have rather counterintuitive consequences. For example, bypass surgery is usually very extensive, but far from being harmful it is actually life-saving. (I'm not saying that circumcision is comparable to bypass surgery; I'm just using it to illustrate the distinction between harm and extensiveness.)

I agree that the response has seemed blown out of proportion, and that it distorted what the AAP is doing. But I think you're missing something big here, namely, that girls' and women's autonomy is currently being undermined by restrictions on abortion and reproductive rights. I can certainly understand how, in that context, the symbolism involved in doing anything harmful to women's or girls' clitorises raises hackles.

That context also explains what's different from male circumcision and FGM: the latter is symbolic of women's (lack of) reproductive autonomy generally, while the former is not.

I think that many feminists tend to think that this point ought to be obvious, and so don't spell it out.

For the record, I'm strongly against male circumcision because I care about autonomy. But a narrow focus on the narrow case of what happens to the genitals of infants can make one miss what's really going on here.

Jake,

Removing healthy skin and nerves is objective harm, as evidenced by the inevitable scarring post-circumcision.  (The risk of further complications constitutes a form of harm, as well.)  I recognize that the AAP used the word 'extensive', which I quoted in my original entry, but you can't pretend that's synonymous with 'harmless'. A logical consideration of MGC in the context of the AAP's policy statement on FGC reveals this.

Anyway, you're still arguing for your utilitarian conclusion that the benefits outweigh the harms.  You're wrong as a matter of policy because your conclusion is relevant only as it pertains to you for your body.  Individually for each child, the potential benefits are of subjective value while the harms consist of subjective possibilities and objective outcomes.

Your example shows your error. Bypass surgery is life-saving, but it is also objectively harmful because it involves cutting into the body.  There, an objective benefit (i.e. cleared arteries) is derived - or anticipated, depending on the actual results - because the surgery is medically necessary.  I'm not aware of anyone who undergoes elective bypass surgery without an underlying medical condition suggesting some degree of need for intervention. The normal, healthy male foreskin is not an underlying medical condition suggesting some degree of need for intervention.

Tony,

Removing healthy skin and nerves is objective harm, as evidenced by the inevitable scarring post-circumcision.

Firstly, I think you're failing to distinguish between whether you think that circumcision is harmful and whether the AAP thinks that circumcision is harmful. I know that you believe that circumcision is harmful, but that's not what we're discussing, is it? Personally, I do not agree that removing healthy skin and nerves is automatically harmful; I think one would have to consider the benefits and risks together to decide whether there is a net harm. But, of course, we're not discussing my views either, but the AAP's.

I recognize that the AAP used the word 'extensive', which I quoted in my original entry, but you can't pretend that's synonymous with 'harmless'.

Perhaps you misunderstood. I'm not saying that "extensive" means "harmless". I'm saying that "extensive" and "harmful" are largely unrelated concepts.

Anyway, you're still arguing for your utilitarian conclusion that the benefits outweigh the harms. You're wrong as a matter of policy because your conclusion is relevant only as it pertains to you for your body. Individually for each child, the potential benefits are of subjective value while the harms consist of subjective possibilities and objective outcomes.

I accept that you disagree, but that doesn't mean that I'm wrong. It just means that we disagree.

Your example shows your error. Bypass surgery is life-saving, but it is also objectively harmful because it involves cutting into the body.

I would suggest that, since it is life-saving, there is a net benefit (as opposed to a net harm). This is my point: even though it is extensive surgery, it is not harmful, on balance, but rather quite the opposite. (Yes, there are some harmful properties, as with many things, but the benefits so outweigh the harms that it is regarded as a net plus.) So it is rather unreasonable of you, I feel, to interpret the AAP's words in the way that you do.

Wow. This discussion really shows a complete lack of understanding about the additional issues involved with FGM. It's no wonder that alliance building between feminists and anti-circumcision men is difficult.

Jake,

When I described the harm of bypass surgery, I did not intend to imply that I believe it to be a net harm. It is not, by some objective measure. (I assume the number of individuals who reject bypass to be greater than zero when some form of need exists, which is useful to the issue at hand.) But that conclusion of net benefit relies on the underlying need addressed, unless you believe some healthy individuals choose elective bypass surgery for some reason. There is no underlying need to non-therapeutic circumcision. When decisions are made for another, it's a reasonable minimum standard to expect some medical need before intervening with surgery for that person. I don't believe you'd defend non-therapeutic bypass surgery on a healthy child via proxy consent.

I know you think one would have to consider the benefits and risks together, though, which justifies circumcision for you. I agree with you that the benefits and risks must be factored as a whole. (You won't see me outright deny potential benefits.) The problem is who decides. You've decided that there is a net benefit, for you. I have decided the opposite, for me. Only the individual can accurately decide for himself, so the decision must be left to him where need is absent. I would not choose circumcision for myself, if I had my decision. I don't, because my parents took it from me. That was, and is, wrong because I was healthy at the time and circumcision is a permanent altering of my body and how it functions. No matter how many times we go back-and-forth on this, I'm going to remain correct on this point.

As for what the AAP believes, I'm arguing that they understand male circumcision perfectly well. This is why I used the word indirectly in my footnote. It is why I wrote my initial entry on the revised policy the way I did. The AAP are not explicit in showing their understanding, but they grasp the concepts. A single read-through of the document demonstrates that. So, I'm not saying that the AAP are imbeciles. I'm saying they do not put forth equal defenses for the rights and needs of girls and boys. The AAP are cowards.

Dan,

I haven't stated my opinion on abortion or reproductive rights beyond FGC. On the latter, I specifically wrote that I'm against any compromise on existing laws prohibiting all non-therapeutic female genital cutting of minors. How do you draw the conclusion that I've missed anything regarding female genital/reproductive autonomy?

I understand why the revised policy statement is generating outrage. In America any form of female genital cutting is perceived to be the worst form. It is perceived to be perpetuated for one reason, to eliminate female sexual pleasure. It is perceived to be solely carried out by or at the direction of men. Patriarchy and all that. These perceptions stand in the face of evidence to the contrary that these scenarios, while common, are not exclusive. Lesser forms and reasons are generally denied when the topic arises, to the discredit of the person unwilling to acknowledge facts. So, the response here is entirely unsurprising. It should've been predictable for the AAP.

The unrelenting demand of many feminists that female genital cutting is always worse than male genital cutting is a reason alliance building between feminists and anti-circumcision men is difficult. The belief that the patriarchy is to blame for one but can't be to blame for the other is another reason. The belief that women do not perpetuate FGC is another. The belief that men would be even more sex-crazed is another, although it's an uncommon belief. A deference to religion and culture is another. A belief that male genital cutting is acceptable because it decreases certain risks for women is another. A determination to shout down any comparison in principle of female and male genital cutting is another. A misunderstanding of anatomy that expects me to accept that the female equivalent to male circumcision is removal of the clitoris is another reason. There are more...

I'll grant you that my list of why we can't find common ground is one-sided. My assesment is fair because I already recognize that non-therapeutic genital cutting on a non-consenting individual is wrong. Gender doesn't factor into that. Nowhere have I said that I believe FGC and MGC as commonly practiced are comparable in degree. Yet, when I say FGC and MGC are the same in kind, I'm often nonsensically accused of downplaying the harm of FGC.

Basically, my interactions with feminists suggests that too many believe in treating females and males as separate classes when considering principles, rights, and policy. Not all believe that, but finding enough common ground with those who do is not possible. I'm not interested in pretending that males aren't victims because females are often greater victims.

If you'd like to show me where I've missed something, I'll happily engage the discussion.

When I described the harm of bypass surgery, I did not intend to imply that I believe it to be a net harm.

Apparently, then, I misundersood. My apologies for that.

It is not, by some objective measure. (I assume the number of individuals who reject bypass to be greater than zero when some form of need exists, which is useful to the issue at hand.) But that conclusion of net benefit relies on the underlying need addressed, unless you believe some healthy individuals choose elective bypass surgery for some reason.

I think we're both talking about bypass surgery due to some pre-existing condition. If it were otherwise, the risk/benefit balance would be very different, I'm sure, and it would be a net harm.

There is no underlying need to non-therapeutic circumcision.

Obviously, by definition. But I think you're missing the point: I haven't said that the circumcision is comparable to bypass surgery. I have used bypass surgery for one reason and one reason only, and that is to show that "extensive" does not imply "net harm". Since we seem to be in agreement that bypass surgery is extensive and does not cause net harm, can we agree that the AAP's statement about circumcision being "extensive" does not imply that they believe (note my careful choice of words) that circumcision is harmful?

When decisions are made for another, it's a reasonable minimum standard to expect some medical need before intervening with surgery for that person.

You've made that statement before, I believe, and I'm sure you're aware that I do not agree with it.

I don't believe you'd defend non-therapeutic bypass surgery on a healthy child via proxy consent.

Of course not. All that risk, and for what benefit?

I know you think one would have to consider the benefits and risks together, though, which justifies circumcision for you. I agree with you that the benefits and risks must be factored as a whole. (You won't see me outright deny potential benefits.) The problem is who decides. You've decided that there is a net benefit, for you. I have decided the opposite, for me. Only the individual can accurately decide for himself, so the decision must be left to him where need is absent.

Sorry, I don't find that argument persuasive. Should children be left unvaccinated so they can weigh the risks and benefits of vaccination for themselves? Uneducated, for similar reasons? Of course not - the proposition seems rather absurd. (And to save us having the standard debate, I know that there are certain differences between, for example, circumcision and vaccination, but those differences do not mandate different treatment, from my perspective.) Parents make many decisions for their children, and sometimes unfortunately they make decisions which the child later resents. I would have preferred to have been circumcised as an infant. You resent that you were circumcised as an infant. I'm sorry that this is the case, but really it's just bad luck.

No matter how many times we go back-and-forth on this, I'm going to remain correct on this point.

Or at any rate, you will continue to believe that you're correct. :-)

This conversation is interesting, but I don't wish to circle the core question: who should make unnecessary medical decisions?

That you believe there's any other answer than that which I state is mind-boggling. I know we've had the discussion before, and I'm certain you're not going to change your mind. But the facts do not change, no matter how many new studies or extensions of prior studies you quote. Circumcision is permanent. It carries risk. It alters the functional process of sexual activities. Any one of these individually settles the question as it pertains to healthy children. Only the person affected by the decision may legitimately decide. I know you disagree with that. But you're wrong. Being witty in your rebuttal won't change the facts or the singular conclusion.

But you want to include potential benefits. Fine, let's do so, although I'd also like to avoid the standard debate on circumcision and vaccination. It's tedious and distracting. I'll leave it at your assessment that there are relevant differences, since I'm sure you realize those aren't trivial.

But it's useful to consider the extent of parental consent and obligation. Which of the potential benefits you favor are not preventable or treatable with less invasive, non-permanent bodily alteration? Which of the potential drawbacks of leaving a child uneducated are avoidable without an education? The difference in the nature of these questions is the gap that forms your error.

As for it being "just bad luck" that my parents circumcised me, I reject that. Growing up poor as a result of their choices was just bad luck that I was able to overcome based on my ability and willingness to work hard. Their decision to circumcise me as a healhty infant was based on their own ignorant, selfish reasons. It was a violation of my body that I can't overcome. It was objectively offensive.

Circumcision is permanent. It carries risk. It alters the functional process of sexual activities. Any one of these individually settles the question as it pertains to healthy children. Only the person affected by the decision may legitimately decide.

Your third assertion seems questionable, but there's no argument that it is permanent and that there is some associated risk. However, your last assertion seems most dubious of all. Are you seriously suggesting that any permanent change "settles the question"? That seems remarkably extreme. Must a child, then, decide for himself about vaccinations, since those are permanent?

On the subject of risk, I believe it would be foolish to consider only risks associated with circumcision and not risks associated with non-circumcision. If, as you suggest, exposure to risk "settles the question" (though I personally disagree with such an absolutist position), then surely it is essential to determine which choice minimises total risk?

On a related note, you ask: "Which of the potential benefits you favor are not preventable or treatable with less invasive, non-permanent bodily alteration?" I don't believe that this question is even relevant. Whether it can be prevented with other means is a moot point unless it actually is prevented with other means. If it is not, then the risk exposure must still be counted. Also, methods of risk reduction are rarely mutually exclusive, so one might also consider circumcision plus other methods, which may be expected to reduce risk further. The simplistic view in which there is circumcision on one hand and something "less invasive, non-permanent" on the other has little, if any, connection with reality.

As for it being "just bad luck" that my parents circumcised me, I reject that. ... Their decision to circumcise me as a healhty infant was based on their own ignorant, selfish reasons. It was a violation of my body that I can't overcome. It was objectively offensive.

There are men who weren't circumcised as infants who similarly curse their parents' decisions. I'm sorry that you feel the way you do. I'm sorry that those men do, too. But I don't accept your view that you were wronged.

*eagerly waits for Tony's response*

Jake said:

"(And to save us having the standard debate, I know that there are certain differences between, for example, circumcision and vaccination, but those differences do not mandate different treatment, from my perspective.)"

It's not clear from your continued comments and continued comparison that you do understand the differences between them.

My statement that circumcision alters the functional process of sexual activities is not questionable. I used the word alters with a purpose. It is not about a subjective call on better or worse. It is a factual statement about process.

An example: For IVF treatment, part of the process is obviously sperm collection. The sample must be collected without benefit of a lubricant. For an intact male, this is unlikely to be a problem. For a circumcised male, this is a painful problem. The functional process of sexual activities is different with and without circumcision. QED

Note, too, that I did not state that any permanent change settles the question. I stated that any permanent change to healthy children settles the question. That is with respect to circumcision, as I thought we'd agreed that there are differences between circumcision and vaccination. I know you'll reject my view on the differences, but it's clear that Joe's assessment is correct. The differences between non-therapeutic circumcision and vaccination are not trivial, unless, for example, you think transmission of HIV and measles is the same. Do you?

On the subject of risk, I believe it would be foolish to consider only risks associated with circumcision and not risks associated with non-circumcision. ...

On the subject of risk, I believe it would be foolish to consider only risks associated with female genital cutting and not risks associated with non-female genital cutting. On the subject of risk, I believe it would be foolish to consider only risks associated with infant mastectomy and not risks associated with non-infant mastectomy. On the subject of risk, I believe it would be foolish to consider only risks associated with appendectomies and not risks associated with non-appendectomies.

That framing is a useless turn away from reality. Life involves risk. If we take your angle as valid, especially given how we (stupidly) value parental whim with male circumcision, then any intervention that might have an effect can be considered and applied, whether necessary or not, and without regard for the absolute risks of the "non" surgically-altered state. Subjective weighting can get anyone to any conclusion.

That framing also ignores the difference between circumcision and the application of circumcision. I don't value the risk reduction I received, although I recognize that some level of risk reduction likely occurred. I genuinely do not care that I'm x% less likely to become HIV positive should I ever have sex with an infected woman, or that I'm n times less likely to develop a UTI. So, contrary to your assumption, I have considered the risks of "non-circumcision". I choose differently than you for myself. That's why you're wrong on how to apply circumcision. I'm correct because I consider each individual, too.

On a related note, you ask: "Which of the potential benefits you favor are not preventable or treatable with less invasive, non-permanent bodily alteration?" I don't believe that this question is even relevant. Whether it can be prevented with other means is a moot point unless it actually is prevented with other means. ...

This works against you as much as it works for you. Circumcision's prophylactic benefits are a moot point unless it actually prevents what it allegedly protects against. You can't prove that, of course, so touting the benefits to a healthy child is mere speculation. That's not an ethical or medical standard for proxy consent for an objectively healthy child.

You also ignore that treatment is a valid consideration. I'd rather treat a UTI and have my foreskin than not have a UTI or my foreskin. Etc.

... If it is not, then the risk exposure must still be counted. ...

You assume I haven't counted it? Circumcision has potential benefits, whether or not I agree with you on the magnitude of those benefits. But I factor the risk exposure as it applies to me. I'd risk my health by the small measure associated with the foreskin to have my normal, healthy genitals (and autonomy). You're demanding that I substitute your judgment for mine as it applies to me. You have a certain risk aversion and you expect me to share it. I do not.

Also, methods of risk reduction are rarely mutually exclusive, so one might also consider circumcision plus other methods, which may be expected to reduce risk further. The simplistic view in which there is circumcision on one hand and something "less invasive, non-permanent" on the other has little, if any, connection with reality.

This is a useful point. But it doesn't change the difference between circumcision and applying circumcision. Touting it as a complementary method relies on the former, while ignoring the latter. Whether an individual wants or needs potential extra benefit from circumcision (e.g. condoms for HIV prevention versus condom and circumcision for HIV prevention) is subjective to him. If an adult male values it and chooses circumcision voluntarily after assessing his risks, wants, and needs, there's no issue. But in applying it to a child, parents weight their guesses more than his lack of need. They've applied it incorrectly (i.e. unethically).

There are men who weren't circumcised as infants who similarly curse their parents' decisions. I'm sorry that you feel the way you do. I'm sorry that those men do, too. But I don't accept your view that you were wronged.

Do you lack the empathy to understand that other people think differently about themselves than you think about yourself?

Everything else you've said is fine, a difference of opinion at best, a misunderstanding of certain facts at worst. I'm mature enough to understand that I'm not always right and that I'm not always going to convince everyone when I am (as I am here). And I've worked on this topic long enough to understand the usual blinders.

But forget that. Your rejection of my view about me pisses me off. It's arrogant of you to think you know better about my body than I do. (Or that my parents knew better than I do.) Men who curse their parents' decision to leave them intact have a solution to make their normal body reflect their preference. I do not have my normal body. My choice is gone. My right to be free from harm was violated. Upset intact men do not have a "right" to grow up circumcised. Equating the two, as you implicitly do, is ridiculous.

My parents had me mutilated. It is definitionally true, and anecdotally verifiable every time I see my penis. Intent, potential benefits, cultural inclusion or any other nonsense used to excuse circumcision (mine or otherwise) does not alter that fact or magically render it acceptable. You might recognize that if you stopped elevating the subjective to the same level of the objective and stopped viewing the collective as a suitable substitute for the individual.

At its core, your conclusion treats children as property. It means that my body belonged to my parents until I became an adult, and the only thing that saved me from other abuses was my "good luck" to be born into flawed American societal norms rather than some other country's whose lack of protections was worse. That's offensive. My body was and is mine, from birth until death. There rests the difference between circumcision and the application of circumcision.

To respond to Joe:

"(And to save us having the standard debate, I know that there are certain differences between, for example, circumcision and vaccination, but those differences do not mandate different treatment, from my perspective.)"

It's not clear from your continued comments and continued comparison that you do understand the differences between them.

I think it would be more accurate, Joe, to say that you and Tony believe those differences to be significant in this context, while I don't,

An example: For IVF treatment, part of the process is obviously sperm collection. The sample must be collected without benefit of a lubricant. For an intact male, this is unlikely to be a problem. For a circumcised male, this is a painful problem.

That's something of a generalisation, but no doubt you're aware of that. I take your point that masturbation can sometimes require a different technique. I think, however, that providing a clinical sample under exceptional conditions is a bit of a stretch as an example of a "sexual activity".

Note, too, that I did not state that any permanent change settles the question. I stated that any permanent change to healthy children settles the question. That is with respect to circumcision, as I thought we'd agreed that there are differences between circumcision and vaccination.

If you're saying that any permanent change to healthy children settles the question, then surely that means any change? And since both circumcision and vaccination are permanent changes to healthy children, then surely the question is settled in both cases? If not, then you must mean something other than "any" change — perhaps you mean something more like "all changes meeting criteria X and Y that affect healthy children settle the question." But if that's the case then you've stated the rule incorrectly, and you need to specify what X and Y are before we could discuss it further.

The differences between non-therapeutic circumcision and vaccination are not trivial, unless, for example, you think transmission of HIV and measles is the same. Do you?

There are similarities, and differences, too. In some situations those differences are important, and in others they are not. Plausibly reasonable people might disagree over which situations those are. I think a better question is: given a particular context, X, may they be considered as effectively the same?

On the subject of risk, I believe it would be foolish to consider only risks associated with female genital cutting and not risks associated with non-female genital cutting. On the subject of risk, I believe it would be foolish to consider only risks associated with infant mastectomy and not risks associated with non-infant mastectomy. On the subject of risk, I believe it would be foolish to consider only risks associated with appendectomies and not risks associated with non-appendectomies.

Okay. I believe that weighing these risks consciously and explicitly will get to the same answer as the immediate "gut feeling" response, but it does no harm.

That framing is a useless turn away from reality. Life involves risk. If we take your angle as valid, especially given how we (stupidly) value parental whim with male circumcision, then any intervention that might have an effect can be considered and applied, whether necessary or not, and without regard for the absolute risks of the "non" surgically-altered state. Subjective weighting can get anyone to any conclusion.

I doubt it. Most interventions are net harms.

That framing also ignores the difference between circumcision and the application of circumcision. I don't value the risk reduction I received, although I recognize that some level of risk reduction likely occurred. I genuinely do not care that I'm x% less likely to become HIV positive should I ever have sex with an infected woman, or that I'm n times less likely to develop a UTI. So, contrary to your assumption, I have considered the risks of "non-circumcision". I choose differently than you for myself.

Firstly, I should point out that you're actually alive at this moment. You could be dead due to complications of UTI or HIV. Presumably you care about being alive. Secondly, if you truly don't care about exposure to UTI or HIV, you're extremely unusual. Put another way, it would be so implausible that a child would not care about these things that it would be unreasonable to assume that he wouldn't.

This works against you as much as it works for you. Circumcision's prophylactic benefits are a moot point unless it actually prevents what it allegedly protects against. You can't prove that, of course, so touting the benefits to a healthy child is mere speculation.

It's a statistical certainty, but in any individual case one can only know probabilities. I don't view that as a problem.

You also ignore that treatment is a valid consideration. I'd rather treat a UTI and have my foreskin than not have a UTI or my foreskin. Etc.

I suppose it would be reasonable to consider treatment of disease as one of the costs in a model, yes.

You assume I haven't counted it? Circumcision has potential benefits, whether or not I agree with you on the magnitude of those benefits. But I factor the risk exposure as it applies to me. I'd risk my health by the small measure associated with the foreskin to have my normal, healthy genitals (and autonomy). You're demanding that I substitute your judgment for mine as it applies to me. You have a certain risk aversion and you expect me to share it. I do not.

On the contrary, you're demanding that parents substitute your judgement for theirs. You're demanding that they assume that children will grow up to be (in short) like you, and take steps that you believe would maximise your own happiness. I have to say, that comes across as rather self-centred. My point of view is that you can't avoid the risk that the child might resent the decision, since if you circumcise there's a risk that he'll wish he hadn't been, and if you don't there's a risk that he'll wish that he had been.

If an adult male values it and chooses circumcision voluntarily after assessing his risks, wants, and needs, there's no issue. But in applying it to a child, parents weight their guesses more than his lack of need. They've applied it incorrectly (i.e. unethically).

Sorry, I disagree: lack of need is not an argument for or against something. It's just a lack of need. So to imply that it should outweigh anything else strikes me as absurd. If you said "parents weight their guesses more than the risk that he might resent it", you'd at least have an argument (albeit not one with which I agree).

[Responding to] "There are men who weren't circumcised as infants who similarly curse their parents' decisions. I'm sorry that you feel the way you do. I'm sorry that those men do, too. But I don't accept your view that you were wronged."

Do you lack the empathy to understand that other people think differently about themselves than you think about yourself

Empathy's about understanding how people feel. I do understand that you resent having been circumcised. But human rights and ethical frameworks are intellectual constructs, and they aren't directly related to how one feels. It's possible to feel angry about something without having had one's rights violated, and that is the case, in my opinion.

Your rejection of my view about me pisses me off. It's arrogant of you to think you know better about my body than I do. (Or that my parents knew better than I do.) Men who curse their parents' decision to leave them intact have a solution to make their normal body reflect their preference.

Not really, no. Cosmetically, an adult circumcision is not the same as an infant circumcision. An adult circumcision always leaves a scar, and usually suture marks.

I do not have my normal body. My choice is gone.

You have a choice to restore your foreskin, if you want to. It's not exactly the same either.

My parents had me mutilated. It is definitionally true

Not according to the senses you cite. Given that circumcision does not make imperfect, and that the foreskin is neither a limb nor an essential part, how do you reckon otherwise?

At its core, your conclusion treats children as property

Nonsense. Children are not property, but parents have to make decisions for their children all the time, and often that's on the basis of guesswork. And I'm afraid that sometimes the decision they make is not the same as the decision which you would make.

Jake said:

"I think it would be more accurate, Joe, to say that you and Tony believe those differences to be significant in this context, while I don't,"

I think it would be even more accurate to say that most people believe those differences to be significant in most contexts while you don't. The only similarity these two things have in common are that they are performed or provided (usually) by someone associated with the medical profession. Perhaps if your context included low efficiency (effectively failed) vaccines which might only be useful, be considered, in limited populations with high-risks for a specific problem then you might be able to stretch your analogy a bit but not in the most common case in the general population.

To illustrate the difference, perhaps you could share a more effective (practical) way to protect oneself from (or treat) the Measles then the current vaccination.

think it would be even more accurate to say that most people believe those differences to be significant in most contexts while you don't.

Perhaps, perhaps not. I don't presume to know what most people believe.

The only similarity these two things have in common are that they are performed or provided (usually) by someone associated with the medical profession.

Incorrect. That is not the only similarity. There are others. For example, both reduce the risk of one or more diseases. Another is that both have associated risks. Another is that both involve breaking the skin using a metal implement. Yet another is that both are often performed during infancy or childhood, frequently without the consent of the individual concerned.

Any of the similarities might be sufficient in a particular context, though not in other contexts. And any of the differences might be significant in one context but not in another.

If we consider this specific situation, Tony proposed a rule which was, to paraphrase, unless something is essential, the decision must be left to the individual. Okay, it's therefore valid to test this rule against anything that is non-essential. That's the only criterion specified, so it is quite legitimate to choose anything that meets it. Vaccinations are not essential (though often highly advisable), so they qualify.

And when we test the rule against vaccinations, we find a result that seems rather absurd. (That's why this technique is called reductio ad absurdum.) There are two — and only two — valid conclusions. The first is that vaccinations without direct consent are unacceptable. The second is that the rule, as stated, is wrong, and may be revised or completely abandoned.

If you choose to propose a new rule, that may well change the context, thus making different similarities and/or differences relevant.

If you take my point that masturbation can require a different technique, and you'd be a fool not to, then you concede my point that circumcision alters the functional process of sexual activities. It doesn't matter one bit that you think the scenario is a stretch. The focus was masturbation, not IVF treatment. Unless men only masturbate for IVF treatment, I'm correct. You're factually wrong. Admit it.

If you're saying that any permanent change to healthy children settles the question, then surely that means any change? And since both circumcision and vaccination are permanent changes to healthy children, then surely the question is settled in both cases? ...

I'll clarify: any surgical change to a healthy child. Since it's clear we have to say more on circumcision versus vaccination, they are "breaking the skin using a metal implement," but that's a silly comparison when examined critically. Vaccination works with the body's immune system, triggering its processes. Circumcision removes a normal, functioning part of the body because it might cause some problem, someday. That's a significant, non-trivial difference.

This shows your fallacy, as well:

...I think a better question is: given a particular context, X, may they be considered as effectively the same?

Okay, here's the context. When are infants going to have sex with an HIV-infected woman, thereby offering them the protection from HIV presumably provided by (voluntary, adult) circumcision? When are infants going to have sex with an HPV-infected woman, thereby offering protection? When are they going to come into contact with measles?

I doubt it. Most interventions are net harms.

This is the crux. The word net is the signal that you're making a judgment call. That's what I've said all along. In that context, you're dealing with subjective weights for each item for your speculative pursuit. The only objective is health at the time of the intervention. That is what must decide the issue regarding proxy consent for invasive surgery. If there's no need, only the individual himself may rightly consent.

Firstly, I should point out that you're actually alive at this moment. You could be dead due to complications of UTI or HIV. ...

This is a joke, right? I could be dead, although not from HIV, since I've never engaged in sex with an HIV+ female (or in a high-risk population). But if I'd kept my foreskin, and developed a UTI, what are the actual odds that I would die from it? Absolute risk, give me a number. You'll forgive me in advance, though, if I choose to be rational and not believe in fear-based decision-making.

... Secondly, if you truly don't care about exposure to UTI or HIV, you're extremely unusual. Put another way, it would be so implausible that a child would not care about these things that it would be unreasonable to assume that he wouldn't.

Why? I don't agree with your assumption because you're measuring the subjective as objective again. If we assume a child doesn't want a given risk, any intervention that might reduce it and doesn't cause death becomes acceptable. That's absurd.

But let me clarify. I do not want a UTI or HIV. My implication is that I value having my foreskin (i.e. my normal body) more than I value the relative risk reduction from not having it. On subjective matters, I can't make it any clearer: I draw a different conclusion than you about what I value and don't worry about. That doesn't make me unreasonable, just different from you.

It's a statistical certainty, but in any individual case one can only know probabilities. I don't view that as a problem.

You don't view that as a problem in your argument, but you're content to deploy it as a tactic against my argument? You just wrote that I could be dead but for my circumcision. That's not consistent or fair.

On the contrary, you're demanding that parents substitute your judgement for theirs. You're demanding that they assume that children will grow up to be (in short) like you, and take steps that you believe would maximise your own happiness. I have to say, that comes across as rather self-centred. ...

Nope. I'm demanding that parents not substitute their judgment for their healthy son's. That's what you miss. I demand that they assume/understand their sons might grow up to think like me. And statistics among intact adult males choosing versus not choosing circumcision demonstrates that the majority of men don't choose it. I'm correct because I've tested my assumptions against realities, not against my preferences.

I accept that some adult males will choose circumcision for themselves. You chose it for yourself. Good for you. I'm sure you made the right decision for yourself. Do you see me telling you that you're wrong for choosing it, substituting my judgment for yours? Have I written anything that says you shouldn't have been allowed to choose it because I wouldn't choose it? Again, this issue is the application of circumcision, not circumcision itself.

... My point of view is that you can't avoid the risk that the child might resent the decision, since if you circumcise there's a risk that he'll wish he hadn't been, and if you don't there's a risk that he'll wish that he had been.

As I wrote, you're equating the right to be free from harm with a "right" to grow up circumcised. You're wrong. Stop.

Sorry, I disagree: lack of need is not an argument for or against something. It's just a lack of need. ...

Then you open yourself to defend anything monstrous the human mind can conjure. Infant mastectomy? Well, the fact that the girl is healthy is insufficient. Let's probe more to see if we should intervene. It's stupid. And the flap over the AAP's revised statement shows that people understand it to be true, even if most mistakenly misunderstand its full, equal application.

... So to imply that it should outweigh anything else strikes me as absurd. If you said "parents weight their guesses more than the risk that he might resent it", you'd at least have an argument (albeit not one with which I agree).

Nope, you're still weighting the subjective equal to the objective. Again, I don't think you understand the distinction between circumcision and its application. It's clear that you think "circumcision is good" means it can applied without concern for other factors than "it's good."

Empathy's about understanding how people feel. I do understand that you resent having been circumcised. But human rights and ethical frameworks are intellectual constructs, and they aren't directly related to how one feels. It's possible to feel angry about something without having had one's rights violated, and that is the case, in my opinion.

Then you don't understand human rights and ethical frameworks. My parents allowed a doctor to take a scalpel to my healthy genitals. They inflicted harm without a reasonable expectation of improving my health? (They couldn't improve it since I was healthy.) If I'd been born a girl, everyone in my society would've recognized that action as an abomination. Equal rights do not depend on gender.

Not really, no. Cosmetically, an adult circumcision is not the same as an infant circumcision. An adult circumcision always leaves a scar, and usually suture marks.

And infant circumcision is not the same as adult circumcision, apart from the obvious point about choice. Do you assume infant circumcision doesn't leave a scar? If so, you're wrong. Do you believe it doesn't leave other marks? If so, you're wrong. It would be a brief exercise to find pictures of typical circumcised penises that look like a dog's chew toy.

(And there's more to it than just scarring and suture marks, like whether to keep the frenulum and how much skin to remove.)

The difference is you got to choose to put those on your body. I didn't. If you didn't value scarring and suture marks less than the benefits you perceived from circumcision, you wouldn't have chosen circumcision. Again, I didn't get my choice to express my preference.

You have a choice to restore your foreskin, if you want to. It's not exactly the same either.

Not exactly the same, indeed. Nor should I have to go through that work to get back a poor facsimile of what I had. Again, human rights and ethical frameworks.

Not according to the senses you cite. Given that circumcision does not make imperfect, and that the foreskin is neither a limb nor an essential part, how do you reckon otherwise?

Circumcision makes imperfect. It "cuts up or alters radically." (e.g. alter the functional process of sexual activities) I recognize the difference between English and American English, but those differences are not great enough to get from those words to where you want to go.

Nonsense. Children are not property, but parents have to make decisions for their children all the time, and often that's on the basis of guesswork. And I'm afraid that sometimes the decision they make is not the same as the decision which you would make.

They don't have to make this decision for their sons. That's why their son's objective health is the vital fact. Making their son's decision when he is healthy treats his genitals as their property. For perspective, surely you've encountered parents who circumcise because the mother prefers circumcised penises, as if that's relevant when she isn't going to have sex with her son. Altering their son's penis is no different to them than picking out new curtains.

I'll clarify: any surgical change to a healthy child. Since it's clear we have to say more on circumcision versus vaccination, they are "breaking the skin using a metal implement," but that's a silly comparison when examined critically. Vaccination works with the body's immune system, triggering its processes. Circumcision removes a normal, functioning part of the body because it might cause some problem, someday. That's a significant, non-trivial difference.

Okay, so you're making a special case for surgical procedures, as opposed to non-surgical. Special cases tend to be symptoms of a desire to reach a specific conclusion, rather than an obvious and straightforward conclusion when reasoning from first principles, so we should be suspicious of them. The obvious question when faced with any special case is: why is it justified?

Okay, here's the context. When are infants going to have sex with an HIV-infected woman, thereby offering them the protection from HIV presumably provided by (voluntary, adult) circumcision? When are infants going to have sex with an HPV-infected woman, thereby offering protection? When are they going to come into contact with measles?

The answer in each case is that there is a statistical probability that they will be exposed to these diseases when they are older.

[responding to:] I doubt it. Most interventions are net harms.

This is the crux. The word net is the signal that you're making a judgment call. That's what I've said all along. In that context, you're dealing with subjective weights for each item for your speculative pursuit.

To some extent, yes — there's always a subjective aspect to weighing such things — but since there is near global agreement that good health is a positive and bad health is a negative the level of subjectivity is acceptably small.

The only objective is health at the time of the intervention. That is what must decide the issue regarding proxy consent for invasive surgery. If there's no need, only the individual himself may rightly consent.

So you keep saying.

[responding to:] Firstly, I should point out that you're actually alive at this moment. You could be dead due to complications of UTI or HIV. ...

This is a joke, right? I could be dead, although not from HIV, since I've never engaged in sex with an HIV+ female (or in a high-risk population).

Unless you choose not to have sex with anyone, you have a non-zero risk of HIV.

But if I'd kept my foreskin, and developed a UTI, what are the actual odds that I would die from it? Absolute risk, give me a number. You'll forgive me in advance, though, if I choose to be rational and not believe in fear-based decision-making.

The absolute risk is small, but non-zero. Using figures from Wiswell & Geschke (1989), there were 2 deaths (both due to renal failure) in 35,929 during the first month of life. That's roughly 0.01%, but it's obviously an underestimate since it only covers the first month of life. So for a reasonably conservative estimate, let's say 0.07%.

But let me clarify. I do not want a UTI or HIV. My implication is that I value having my foreskin (i.e. my normal body) more than I value the relative risk reduction from not having it.

Okay, you said earlier that you genuinely didn't care about reduced risk of these conditions. Saying that you do care, but value something else more, makes more sense. I'm afraid that I don't find it a convincing argument, though.

Nope. I'm demanding that parents not substitute their judgment for their healthy son's. That's what you miss. I demand that they assume/understand their sons might grow up to think like me. And statistics among intact adult males choosing versus not choosing circumcision demonstrates that the majority of men don't choose it. I'm correct because I've tested my assumptions against realities, not against my preferences.

There are several problems in your argument here. First of all, we don't actually have statistics on the number of adult males who choose circumcision vs not choosing it. We don't even have statistics on the proportion of uncircumcised men who do elect circumcision as an adult, but even if we did that would be insufficient because we can't say that the remainder chose not to (they might not have even considered it, for example). What we do have are studies of the acceptability of circumcision (see, eg., Westercamp and Bailey), and those indicate that the majority of men would choose to be circumcised if it were available to them.

I accept that some adult males will choose circumcision for themselves. You chose it for yourself. Good for you. I'm sure you made the right decision for yourself. Do you see me telling you that you're wrong for choosing it, substituting my judgment for yours? Have I written anything that says you shouldn't have been allowed to choose it because I wouldn't choose it? Again, this issue is the application of circumcision, not circumcision itself.

Oh no, you haven't indicated at all that I shouldn't have been allowed to choose it. Far from it: you indicate that anyone who'd like to be circumcised should be forced to do so as an adult, to be exposed to the greater risk of complications, the greater cost, time off work, anxiety about surgery, embarassment, abstinence during healing, and so on. And all so that you can have what you want.

[responding to:] ... My point of view is that you can't avoid the risk that the child might resent the decision, since if you circumcise there's a risk that he'll wish he hadn't been, and if you don't there's a risk that he'll wish that he had been.

As I wrote, you're equating the right to be free from harm with a "right" to grow up circumcised.

Care to explain?

[responding to:] Sorry, I disagree: lack of need is not an argument for or against something. It's just a lack of need. ...

Then you open yourself to defend anything monstrous the human mind can conjure. Infant mastectomy? Well, the fact that the girl is healthy is insufficient. Let's probe more to see if we should intervene. It's stupid.

What's stupid? Infant mastectomy? I agree, it's a ridiculous idea, but not because of lack of need. That's an absence of argument for something, which is not the same as an argument against it. Infant mastectomy is a ridiculous idea because there's a clear net harm, with risk, significant loss of function, aesthetic (and probable psychological) harm, and so on.

But the act of considering it isn't stupid. It's merely open-minded, and as a result of doing so we learn more about it.

Then you don't understand human rights and ethical frameworks. My parents allowed a doctor to take a scalpel to my healthy genitals. They inflicted harm without a reasonable expectation of improving my health? (They couldn't improve it since I was healthy.)

The mistake you're making is to assume that the fact that you were healthy at the time implies that you would always be healthy. That's not the case: there is a real probability of ill health later in life, and circumcision reduces some of those risks.

If I'd been born a girl, everyone in my society would've recognized that action as an abomination.

Everyone would have recognised it as rather astonishing, since girls do not in general have a penile foreskin and hence it cannot be done. If somebody were to do a different thing to a girl, then it makes sense to evaluate that on its merits.

And infant circumcision is not the same as adult circumcision, apart from the obvious point about choice. Do you assume infant circumcision doesn't leave a scar? If so, you're wrong. Do you believe it doesn't leave other marks? If so, you're wrong. It would be a brief exercise to find pictures of typical circumcised penises that look like a dog's chew toy.

Infants have a remarkable healing ability, which by itself tends to produce much less scarring. Combine that with the fact that the body part grows a great deal, stretching and smoothing out any scarring, tends to result in less visible scars. Yes, there are occasional exceptions.

Not exactly the same, indeed. Nor should I have to go through that work to get back a poor facsimile of what I had. Again, human rights and ethical frameworks.

It's your choice as to whether you restore your foreskin or not, just as it was mine to decide whether to be circumcised as an adult of not. Claiming that you shouldn't have to is unpersuasive: I could say the same thing. It seems to me that you're trying to avoid acknowledging the fact that neither of us can get exactly what we would have got if our parents had made the decision that we would have liked.

Circumcision makes imperfect.

If anything, I would say that a circumcised penis is more perfect, not less.

It "cuts up or alters radically." (e.g. alter the functional process of sexual activities)

Any differences are trivial at most.

They don't have to make this decision for their sons. That's why their son's objective health is the vital fact. Making their son's decision when he is healthy treats his genitals as their property. For perspective, surely you've encountered parents who circumcise because the mother prefers circumcised penises, as if that's relevant when she isn't going to have sex with her son. Altering their son's penis is no different to them than picking out new curtains.

When a decision falls into the neutral region of acceptable procedures, it doesn't really matter very much what the reasons for it are.

Jake said:
Incorrect. That is not the only similarity. There are others. For example, both reduce the risk of one or more diseases. Another is that both have associated risks. Another is that both involve breaking the skin using a metal implement. Yet another is that both are often performed during infancy or childhood, frequently without the consent of the individual concerned.

Your first point may apply only if we intend to include low efficiency vaccines with very limited applicability. If you're expanding the definition to include such vaccines, as opposed to well tested, universally recommended, reliable ones which have been credited with eliminating or significantly controlling diseases on their own, this may be the case. Your second point is so broad that it could include anything and it's difficult to see why you would choose to include it. Your third point is taken. Though all of these reasons, including mine, are superficial and tells us nothing about why vaccinations are acceptable and why circumcision is, in most cases, not. So to get a firmer idea, perhaps you could share a more effective (practical) way to protect oneself from (or treat) the Measles (or Polio or Diphtheria) then the current vaccination.

Tony said:

But let me clarify. I do not want a UTI or HIV. My implication is that I value having my foreskin (i.e. my normal body) more than I value the relative risk reduction from not having it.

Jake replied:

Unless you choose not to have sex with anyone, you have a non-zero risk of HIV.

The absolute risk is small, but non-zero.

Okay, you said earlier that you genuinely didn't care about reduced risk of these conditions. Saying that you do care, but value something else more, makes more sense. I'm afraid that I don't find it a convincing argument, though.

To my knowledge, Tony has never suggested that there may not be a vanishingly small but non-zero risk reduction of these things in, even in his context. As he correctly points out however, there is also a cost involved, the risk, changes in sexual stimulation, and perhaps some other things which I see you tend to minimize and dismiss to the best of your ability. However, all of these are subjective and rather then wade into the rest of this clutter (there's just too much to shovel) perhaps this can be reduced to a single question, Whom is the person most able to quantify whether (for example) a few tenths or hundredths percent lifetime difference in HIV risk (or other small risks) is worth the costs involved? Who can best evaluate how much Tony would have valued what his foreskin might have provided sexually? ....

Your first point may apply only if we intend to include low efficiency vaccines with very limited applicability. If you're expanding the definition to include such vaccines, as opposed to well tested, universally recommended, reliable ones which have been credited with eliminating or significantly controlling diseases on their own, this may be the case.

I see you've taken my point that the context of a comparison is of critical importance. Plausibly we might not limit our comparison to vaccines alone. The scope might be sufficiently broad to include anything that reduces the risk of disease, such as healthy diets, exercise, etc.

Your second point is so broad that it could include anything and it's difficult to see why you would choose to include it.

I'm including it because it's a similarity, and my purpose was to list some similarities. Simple as that. :-)

Though all of these reasons, including mine, are superficial and tells us nothing about why vaccinations are acceptable and why circumcision is, in most cases, not.

I realise it can sometimes be difficult to distinguish between one's own opinions and objective fact, but I should remind you that the notion that circumcision is not acceptable in most cases is merely your own opinion. It's not provable, except possibly to those who already subscribe to your personal belief system.

To my knowledge, Tony has never suggested that there may not be a vanishingly small but non-zero risk reduction of these things in, even in his context.

I forgot to put it in italics, but I was replying to this: "This is a joke, right? I could be dead, although not from HIV, since I've never engaged in sex with an HIV+ female (or in a high-risk population)."

As he correctly points out however, there is also a cost involved, the risk, changes in sexual stimulation

Of course there are costs involved. Risks, certainly. Sexual stimulation is more dubious, but anyway, yes, there are costs. If there weren't, the decision would be a lot easier.

Whom is the person most able to quantify whether (for example) a few tenths or hundredths percent lifetime difference in HIV risk (or other small risks) is worth the costs involved? Who can best evaluate how much Tony would have valued what his foreskin might have provided sexually?

"The act of measurement always disturbs the object measured" - paraphrasing of the Uncertainty Principle, which seems curiously apt in this situation. The answer is Tony, but only if we deny him the benefits of circumcision during childhood, and put him in a position in which he is forced to undergo adult circumcision in order to enjoy the benefits as an adult. Tony may personally appreciate that, but statistically speaking it seems difficult to justify.

Of course context is important. This is why I said that it doesn't seem to me like you understand the non-trivial (contextual) differences between circumcision and a vaccination. To help you understand the difference, perhaps you could share a more effective (practical) way to protect oneself from (or treat) the Measles (or Polio or Diphtheria) then the current vaccination.

Jake said:"The answer is Tony, but only if we deny him the benefits of circumcision during childhood,

What benefit is being denied? As Tony previously asked, "Which of the potential benefits do you favor that are not preventable or treatable with less invasive, non-permanent bodily alteration?"

Jake said: and put him in a position in which he is forced to undergo adult circumcision in order to enjoy the benefits as an adult.

If Tony, or anyone else, feels that the potential benefits are sufficient enough to undergo adult circumcision then that is their choice. Any hassle, real or perceived, is part of their personal consideration as are any potential alternatives that may be available at the time of their decision.

Jake said:Tony may personally appreciate that, but statistically speaking it seems difficult to justify."

I am not sure what you mean by this.

Jake:

I wrote a much longer response, but I think posting it all would be a repetitive waste of time, a distraction. The key points can be condensed in responses to a few of your comments. It's better to focus because you're still missing the fundamental issue. I can respond to the rest of the comment after we address this.

Also, you didn't acknowledge that I proved my statement of fact about circumcision altering the functional process of sexual activities. An oversight?

Oh no, you haven't indicated at all that I shouldn't have been allowed to choose it. Far from it: you indicate that anyone who'd like to be circumcised should be forced to do so as an adult, to be exposed to the greater risk of complications, the greater cost, time off work, anxiety about surgery, embarassment, abstinence during healing, and so on. And all so that you can have what you want.

I don't know how you get to this, assuming you meant to say I haven't indicated that you should've been allowed to choose it. (Maybe you think I'm supposed to mean parents who want to choose it, since I would prevent them from imposing it?) I can't make it any clearer throughout my writings. You'll find nothing in the thousands of words I've written on circumcision to suggest otherwise.

I recognize that there are trade-offs to adult circumcision. I'm sure they're unpleasant to experience. But, as I've written here and elsewhere on other topics, all individual tastes and preferences are subjective. I know from your decision to have yourself circumcised that you value being circumcised more than you value the greater risk of complications, the greater cost, time off work, anxiety about surgery, embarassment, abstinence during healing and so on. You evaluated the factors for and against and decided that it was worth undertaking. You got what you wanted, which is all I'm advocating. (Do you think being circumcised doesn't cause me embarassment?)

You're wrong if you think I want to protect children so I can have what I want, if you think what I want is for all males to be intact. I want everyone to have their choice, whatever they choose. I've also written in the past that I'm open to males under 18 choosing circumcision for themselves, as long as they're competent to choose and understand the implications. I care about individual choice, not ending all unnecessary circumcisions. Why do you still refuse to understand that this is about the application of circumcision, not circumcision itself?

... "right" to grow up circumcised.

Care to explain?

Sure. Circumcision is harm. We disagree on the net and its implications, but I hope we both agree that it involves some degree of harm. Imposing it on a healthy child changes him from healthy to harmed. He'll heal, but he shouldn't have to, and he'll never get his normal body back. He has a right to be free from that harm, as much as he has a right to be free from a punch to the face. You're saying that I should also factor the risk that he'll wish he had been circumcised. Maybe he will. I accept that possibility, since it's included in my solution. You think that it's justified to go ahead and do it anyway, since he might choose it for himself. You're taking the possibility and converting it to a certainty that, at worst, he won't mind. You imply that not circumcising a male in infancy who ends up wanting to be circumcised has denied him something he deserves. This "right" to grow up circumcised does not exist.

To elaborate, later you wrote:

It's your choice as to whether you restore your foreskin or not, just as it was mine to decide whether to be circumcised as an adult of not. Claiming that you shouldn't have to is unpersuasive: I could say the same thing. It seems to me that you're trying to avoid acknowledging the fact that neither of us can get exactly what we would have got if our parents had made the decision that we would have liked.

This is an example of equating my right to be free from the harm of circumcision and your "right" to grow up circumcised. You equate me deciding whether or not to create a facsimile of my foreskin to your decision to remove your normal foreskin. They are not the same decision. I'm avoiding nothing. You could and did get what you wanted, to the extent that is ethically reasonable. If you wish you'd grown up circumcised, I wish I'd grown up rich. That you had to wait until adulthood to be circumcised is interesting, I suppose, but pointless to the relevant debate about individual children. In my solution, we both ultimately get what we want. In your worldview, you get what you want and I get what you really want.

And, in response to Joe, you wrote:

... The answer is Tony, but only if we deny him the benefits of circumcision during childhood, and put him in a position in which he is forced to undergo adult circumcision in order to enjoy the benefits as an adult. Tony may personally appreciate that, but statistically speaking it seems difficult to justify.

Mixing up deny and force reveals your error. Leaving me intact would not have denied me the potential benefits of circumcision during childhood. Use of deny implies I'm entitled to those potential benefits, that I have a right to grow up circumcised. No such right exists, but I am entitled to my right to be free from harm and my right to bodily autonomy. My parents forced circumcision on me. They denied me my choice to decide whether to undergo adult circumcision or not, whether I wanted those potential benefits or not. You try to justify circumcision with statistics. I am a human being, not a statistic.

Of course there are costs involved. Risks, certainly. Sexual stimulation is more dubious, but anyway, yes, there are costs. If there weren't, the decision would be a lot easier.

But there are always costs involved, which is why I expect you to figure out that each individual is the best (i.e. only) person qualified to decide for himself whether he wants a non-therapeutic surgical intervention or not. Why do you continue missing that only the individual is qualified to make permanent, unnecessary decisions for himself?

I wrote a much longer response, but I think posting it all would be a repetitive waste of time, a distraction. The key points can be condensed in responses to a few of your comments. It's better to focus because you're still missing the fundamental issue. I can respond to the rest of the comment after we address this.

I have a question for you, Tony. How would you distinguish between me missing this fundamental issue, and me disagreeing with it? This is a genuine question, and I'm asking it in an attempt to find out whether you're prepared, even in principle, to accept the latter as a possibility.

Also, you didn't acknowledge that I proved my statement of fact about circumcision altering the functional process of sexual activities. An oversight?

Not an oversight, no. I think you're technically correct, but the technicality is such that I don't find it correct in a meaningful sense. Since you obviously do, there seems little point in continuing that particular debate.

I don't know how you get to this

It's the logical consequence of what you demand.

I recognize that there are trade-offs to adult circumcision. I'm sure they're unpleasant to experience. But, as I've written here and elsewhere on other topics, all individual tastes and preferences are subjective. I know from your decision to have yourself circumcised that you value being circumcised more than you value the greater risk of complications, the greater cost, time off work, anxiety about surgery, embarassment, abstinence during healing and so on. You evaluated the factors for and against and decided that it was worth undertaking. You got what you wanted, which is all I'm advocating. (Do you think being circumcised doesn't cause me embarassment?)

Actually, what I'd truly like is a neonatally circumcised penis, but that's not an option. An adult circumcision is close enough, and yes, it's worth the undertaking. But the point is this: your argument essentially boils down to saying that your "right" to have grown up with a foreskin is more important than my "right" to have grown up without one. And consequently anyone who wants to be circumcised should have to suffer for it. And that position seems rather absurd to me.

You're wrong if you think I want to protect children so I can have what I want, if you think what I want is for all males to be intact. I want everyone to have their choice, whatever they choose.

You make it sound as though a "choice" is such a wonderful thing. But having a choice means they're forced to "choose", in order to be able to enjoy being circumcised.

Sure. Circumcision is harm.

Disagree.

We disagree on the net and its implications, but I hope we both agree that it involves some degree of harm.

That's not the same as saying that it is harm. For something to be harm, in a meaningful sense, it has to be more harmful than beneficial.

You're taking the possibility and converting it to a certainty that, at worst, he won't mind.

On the contrary, I recognise that there is a possibility that he will resent it. But I consider that risk to be acceptably small.

You imply that not circumcising a male in infancy who ends up wanting to be circumcised has denied him something he deserves.

No, but it does mean that his net happiness is reduced.

This "right" to grow up circumcised does not exist.

I agree. Neither does a right to grow up uncircumcised.

This is an example of equating my right to be free from the harm of circumcision and your "right" to grow up circumcised.

Indeed. It was written for that purpose.

In your worldview, you get what you want and I get what you really want.

Wrong. I'm pro-parental choice, not pro-circumcision, and I do not envisage a world with a 100% circumcision rate. I envisage a world much like this one in which some boys are circumcised and some boys aren't. Sometimes (but reasonably rarely) they aren't happy about that, and they may obtain for themselves the best available approximation of what they would like (be that an adult circumcision or foreskin restoration).

Mixing up deny and force reveals your error. Leaving me intact would not have denied me the potential benefits of circumcision during childhood. Use of deny implies I'm entitled to those potential benefits, that I have a right to grow up circumcised.

Then substitute another word without those connotations. My point, I believe, stands.

But there are always costs involved, which is why I expect you to figure out that each individual is the best (i.e. only) person qualified to decide for himself whether he wants a non-therapeutic surgical intervention or not. Why do you continue missing that only the individual is qualified to make permanent, unnecessary decisions for himself?

What you seem not to understand is that the costs of adult circumcision are greater, and the benefits fewer. Consequently if we compare adult circumcision with infant circumcision, infant circumcision comes out as a better choice. The two are not interchangeable, and that's why it's not as simple as you seem to imagine. In your view (correct me if I'm wrong), the ability to have a natural foreskin if so desired is paramount. Because I view the ability to have a natural foreskin as no more important than the ability to have a neonatally circumcised penis, and I recognise that it is impossible to guarantee both, I reject that approach. I look at it as a case of trying to maximise the odds of happiness (including health as well as direct satisfaction with circumcision status).

Jake said:Actually, what I'd truly like is a neonatally circumcised penis, but that's not an option. An adult circumcision is close enough,

For any purpose that matters, they're the same. Though the neonatal is more likely to look like, as Tony described, a dog's chew toy.

Jake said:"And consequently anyone who wants to be circumcised should have to suffer for it. And that position seems rather absurd to me."

In what way does a healthy individual seeking a circumcision "suffer" any more than someone seeking a tattoo or piercing? What is absurd is that someone would encourage a surgical procedure on a non-consenting individual to chase a potential benefit that can be realized in less invasive and often more effective ways.

Jake said: You make it sound as though a "choice" is such a wonderful thing. But having a choice means they're forced to "choose", in order to be able to enjoy being circumcised.

I had no idea that having choice was such a burden for you. Most people I know prefer greater choice.

Jake said: "What you seem not to understand is that the costs of adult circumcision are greater, and the benefits fewer."

You keep saying things like this but won't tell us what benefits Tony would have been denied that, as he put it, "are not preventable or treatable with less invasive, non-permanent bodily alteration?"

I have a question for you, Tony. How would you distinguish between me missing this fundamental issue, and me disagreeing with it? This is a genuine question, and I'm asking it in an attempt to find out whether you're prepared, even in principle, to accept the latter as a possibility.

As long as you believe circumcision is a net benefit, unqualified by the input of the individual being circumcised, you miss the fundamental issue. You think people are the sum of their statistical probabilities as human beings, based on your evaluation of what risks are and are not important. You won't understand that people have different preferences and that the ones you don't agree with are still rational and valid for that individual. You're comfortable with letting one person substitute his/her judgment for another, based on subjective, incomplete calculations.

I'm prepared to accept the latter about you, but the principled requirement is that you recognize that my circumcision was a violation of my body and my rights because I've drawn the conclusions I have for my body based on my experience and my preferences. You're not ready to recognize that because circumcision is “good” to you, which means I must be mistaken. Of course, you can't recognize the individual, lest your fiction fall apart. Instead, you engage in sophistry. Words like deny, harm, force, right, suffer, choice, and mutilate have plain, easy-to-understand definitions that you twist into magical support for your personal conclusions. You approach circumcision with rhetorical tactics of omission that lead you to "circumcision is good" for anyone who receives it, no matter how they receive it or their perception of its value. You think your subjective conclusion about circumcision satisfies all objections to its application.

What you seem not to understand is that the costs of adult circumcision are greater, and the benefits fewer. …

On the contrary, I understand that and will admit as much because I’m honest. But the point proves nothing about how to treat infants. As we agreed earlier, there are trade-offs and costs to the application of circumcision. You didn’t “suffer” from being “forced” to choose to be circumcised. Presumably you understood the drawbacks (i.e. pain, etc) when you chose to have it done, so you demonstrated that you valued the benefits more than the drawbacks and the suffering. No suffering was forced on you because you didn’t have to choose circumcision. A child doesn’t get to choose whether he receives those drawbacks, but if circumcision is forced on him, he suffers them anyway. But because you didn’t like the conscious memory of those things you volunteered for, you’re content to let parents force that suffering onto their children who don’t consent. That’s immature.

… Consequently if we compare adult circumcision with infant circumcision, infant circumcision comes out as a better choice. …

According to your evaluation, not mine. You are right for you, while I am right for me. That is what you insist on not knowing. I don’t value the pros necessary to get me to the conclusion you draw, just like you don’t value the cons necessary to get you to the conclusion I draw. As individuals, we have different preferences. Different solutions are appropriate for each of us, and leaving the choice to its rightful owner is the only solution that satisfies us to the maximum extent possible. Your utilitarianism would recognize that, except you can’t recognize the individual’s involvement. I can’t be an individual to you. I work only as a statistic, a UTI or HIV infection waiting to happen but for the benevolent grace of my parents. Otherwise, you’d have to draw my conclusion about the application of circumcision.

You can’t even admit that a judgment-free statement of fact is correct because you must apply your personal judgment first and therefore determine that this judgment-free statement of fact is irrelevant to everyone, in all scenarios. Until you provide evidence that you understand that non-therapeutic circumcision should only be chosen according to the personal evaluation of the individual affected, I stand by my conclusion that you miss the fundamental issue rather than disagree with it.

@Dan O: "girls' and women's autonomy is currently being undermined by restrictions on abortion and reproductive rights. I can certainly understand how, in that context, the symbolism involved in doing anything harmful to women's or girls' clitorises raises hackles."

A good point, but in this case, the AAP specified that they should not do anything harmful, but merely symbolic, explicitly to replace anything harmful.

Yet the reaction has been as if that gesture was indeed the worst form of FGC. The AAP board seems to have shared this view in retracting their policy, or perhaps Dan O's view about the underlying symbolism of a "ritual nick".

My reading is that the board read the abstract, the recommendations and the press release, not realising how supportive of the "ritual nick" this text tucked away in the actual policy was -

"However, the ritual nick suggested by some pediatricians is not physically harmful and is much less extensive than routine newborn male genital cutting. There is reason to believe that offering such a compromise may build trust between hospitals and immigrant communities, save some girls from undergoing disfiguring and life-threatening procedures in their native countries, and play a role in the eventual eradication of FGC. It might be more effective if federal and state laws enabled pediatricians to reach out to families by offering a ritual nick as a possible compromise to avoid greater harm."

- or that Recommendation 4 of the 1998 policy -

"...that its members decline to perform any medically unnecessary procedure that alters the genitalia of female infants, girls, and adolescents"

- had actually been deleted from the 2010 policy.

The form-letter the AAP CEO and president sent to early complainants -

'To better understand the American Academy of Pediatrics (AAP) position on female genital cutting (FGC), I encourage you to read the policy statement issued April 26. You can see the full statement at: http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;125/5/1088?rss=1

'In the statement, the AAP reaffirms its strong opposition to FGC and counsels its members not to perform such procedures. As typically practiced, FGC can be life-threatening. Little girls who escape death are still vulnerable to sterility, infection, and psychological trauma.

'The AAP does not endorse the practice of offering a "clitoral nick." This minimal pinprick is forbidden under federal law and the AAP does not recommend it to its members.

'The AAP is steadfast in its goal of protecting all young girls from the harms of FGC. '

- suggests they had not read the policy as carefully as outsiders did, or side-by-side with the 1998 policy. This does suggest a communication failure between the Bioethics Committee and the board before the policy was published.

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