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Every Circumcision Includes Affirmable Objective Harm

Disclosure: I am the author of the first link in this post.

The AAP has released its revised statement on non-therapeutic male circumcision, which provides the contradictory conclusions that the possible benefits outweigh the risks (without mention of the costs) and that not everyone will conclude that the possible benefits outweigh the risks for their family. Another prominent libertarian has chimed in on non-therapeutic infant male circumcision, this time with a different take than Doug Mataconis' flawed non-libertarian advocacy from last week. Today, George Mason University Law Professor David Bernstein posted on the revision at The Volokh Conspiracy. He engages in a better approach, but his conclusion is also wrong.

At the risk of provoking the ire of anti-circumcision zealots (you know who are), I thought I’d mention that the American Academy of Pediatrics, reversing a previous neutral stance, is now endorsing male circumcision based on a review of recent scientific evidence.

Zealots. If that's the word choice, then describe the opposition correctly. I oppose non-therapeutic genital cutting (i.e. circumcision) on non-consenting individuals. That is different than being merely anti-circumcision. I don't care if someone has himself circumcised. I care very much if someone is circumcised without medical need and without his consent. This is based on the same principle and understanding of facts that forms my opposition to an individual having her genitals cut without medical need and without her consent.

I undertook a reasonably thorough review of the existing evidence myself, frankly with a bias toward finding that circumcision was overall harmful. I was aware that circumcision, like several other medical procedures (think episiotomy during childbirth) was encouraged for decades by an unthinking medical establishment that didn’t undertake the research needed to support its recommendations. I was perfectly willing to believe that circumcision had few if any health benefits, had significant costs, and should be done only for religious reasons if at all.

I believe that. However, it implies a validity for the decision to circumcise a healthy child that is illegitimate. Proxy consent for surgery must start with medical need, not the possibility of positive benefits. The subjective value of the pursued speculative benefits rests with the decision-maker, not the individual who will live with the surgical alteration to his body. The only objective outcome he receives is the unavoidable physical harm from the surgical intervention.

I couldn’t find such evidence. Instead, I found that it has small but real health benefits, and that there is no sound evidence of reduced sexual function (I know, tons of nerve endings, blah blah blah, but where is the evidence that on average it makes sex less enjoyable? Studies on men circumcised as adults don’t provide such evidence). I’m not sure that would be enough to lead me to circumcise my own son (mostly because of squeamishness) [if I weren't Jewish, and had a son], but I think it’s an easy call if you plan to raise your son Jewish; the last thing you want is for your kid to decide at age 20 or whatever that his religion demands circumcision, and to have to undergo it then, when the risks and pain are much worse. (If there was sound evidence of harm from circumcision, that would be a different story).

I recognize those possible health benefits. I agree they're small, which I'm glad is stated in Prof. Bernstein's post. But there are possible flaws, even outside potential methodological flaws. The obvious ethical flaw is declaring results found with adult volunteers should then be applied at parental request to healthy infants who do not consent.

The non-obvious physical flaw is that infant and adult circumcision are not quite the same procedure. In infancy, the foreskin is fused to the glans. To circumcise a child, his foreskin must be separated from the rest of his penis. The bond formed by the synechia must be broken, which may inflict additional scarring on the glans of the infant. The circumciser must estimate how much skin to remove and work with an obviously much smaller penis. Too little or too much may be removed, assuming the circumcised is even pleased with his parents making his decision. The circumciser also does not know whether to leave or remove the frenulum. (It is usually removed.) These concerns are minimized or non-applicable when waiting until adulthood. There are trade-offs in both directions, not just the alleged preferablity of infant circumcision.

The obvious physical flaw is more apparent. Circumcision inflicts objective harm in every case. The normal, healthy foreskin is removed. Nerve endings are severed. (The absence of evidence on how that affects sexual pleasure is not an argument in favor of infant circumcision. Prof. Bernstein's position incorrectly assumes it favors his analysis.) The frenulum may be removed. Scarring remains. And the risk of further complications exists in every circumcision. Some males will experience complications, including possibly severe complications. That is all sound evidence of harm from every circumcision.

The “right to bodily integrity” argument so popular in Europe these days doesn’t sway me. What if your kid is born with six fingers, or with an ugly mole on his face, neither of which are causing harm beyond the aesthetic, and removal of either of which will cause some pain? Does his “right to bodily integrity” mean that you have to wait until he’s sixteen to let him decide whether to remove the appendage? Those strike me as harder cases than circumcision, given that circumcision actually provides some medical benefits. But I think it would be absurd to ban, or even discourage, removal.

This compares either abnormalities or subjective cosmetic opinions to the normal foreskin. I think it would be less compelling to ban intervention on children in those non-therapeutic cases, as opposed to the clear need to prohibit non-therapeutic child circumcision, but I don't think it's automatically absurd to intervene in those other cases. Still, different opinions are possible. Is Cindy Crawford's mole a cosmetic problem for her? Gattaca has a thought-provoking take on extra digits with "Impromptu for 12 Fingers". There can be unexpected benefits from doing nothing, from leaving the individual his choice.

The crux is to what extent should we value the right to physical integrity more than the possible medical benefits. It's shouldn't be a debate when considering that the harm is objective and the benefits are not. It is more than an unprovable moral notion. Most males will never need the possible benefits cited for non-therapeutic circumcision. And we already recognize the legal harm to females for comparable and lesser forms of harm from non-therapeutic genital cutting. (Yes, there are disparities in the two. They are the same in principle and other important aspects.)

If there was sound evidence that circumcision was affirmatively harmful, I think governments (and busybodies) would have every right to discourage it, including by law for minors, regardless of religious sensitivities. Given that the evidence points in the opposite direction, the movement in Germany and elsewhere to ban circumcision is unconscionable.

That evidence exists. Every circumcision involves objective harm. The science upon which the AAP relies is essentially the subset that supports circumcision, and which is often barely applicable to the United States (e.g. possibly reduced female-to-male HIV transmission in high-risk populations with low circumcision rates). The lack of need - the health of the child - is also science. Less invasive, more effective preventions and treatments for the ailments circumcision may reduce also constitute science. Condoms, antibiotics, Gardasil, soap, and water are science. To suggest a conclusion can be objective on this net evaluation is absurd because that question for each individual is subjective, as evidenced by the AAP's own contradictory statement.

The decision to circumcise healthy children because doing so might help them is not libertarian. As I wrote in Friday's post, let's temporarily assume what is not true, that the foreskin has no purpose. "It's mine" is sufficient. Even within a limited view of the right to physical integrity where objective harm is not viewed as harm, one's body is clearly one's own property. The onus is not properly on the person who may not want his property taken to accept his loss because his property was taken with good intentions for an exchange in value he may not want.

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