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January 22, 2017

I have pessimistic thoughts on protests

Protesting is necessary. There are injustices in the world that won't fix themselves. It takes commitment and bravery to fight because power, the cause of most injustice, loves compliance.

Protest is also dangerous. Some of that is because power¹ loves compliance. Protest needs to remain focused and controlled. I don't want to say "non-threatening", since I don't mean a willingness to accept whatever sham of rights power is willing to concede. No, not that. But at best it will be unpleasant. People whose rights aren't violated - or who are content to have their rights violated, especially - will let you know you should like having your rights violated. They are miserable people. It will be necessary to face and ignore that nastiness.

But the danger I'm thinking of is more the danger from unleashing energy into combatting injustice. It's easy to lose the thread on the principle involved in the fight. It's inviting for anyone with a message to attach themselves to a protest and hijack it for other purposes. It isn't easy to control that, either, because it's seductive to think, "More people are joining us, we're winning!". Maybe, but maybe not.

Obviously the last couple days are on my mind. The protests from both Friday and Saturday reflect my point. Friday it was the predictable violence². It isn't inevitable with a protest with a focused message, but Friday's protests weren't focused. "Anti-Trump" is a choose-your-own-adventure opportunity for grievances. But that also means it's foolish to judge opposition to Trump on this inevitable violence.

Yesterday's protest resulted in no violence, as far as I'm aware. I think that has much to do with coherence on the message. The danger awaits, though, for what the marches hope to accomplish. I've seen many astute voices pointing out that yesterday was the beginning. That's correct. The work begins now. But I don't think that work is to keep the momentum. The work is to prevent the message from fracturing. I'm not optimistic.

The stated principle for yesterday's protest, as I understand it, was that women are human beings deserving equal rights. Great, I'm on board. But it's clear this movement has the potential for power. That focus on principle will disappear. Here, I'll pick a random example I encountered. The list has the above principle. It then expands to the LGBTQ community. I'm still on board because I think this is the same principle at its core. Human beings deserve equal rights. Third is resisting racism. Yep, still there.

Then, with numbers four, five, and six, are climate change, income inequality, and universal health care. That's a fracturing divergence. "... we must immediately address the damage we have done and continue..." I agree that climate change is real, and that humans are a reason. But there's so much room to disagree on how to address the damage. Maybe we'll agree on what to do, but there will be disagreement.

For income inequality, "Wages for working people must rise. Wages for working people must rise. A healthy and growing middle class is not a naturally occurring phenomenon. It must be cultivated through sensible economic policy." I agree that a healthy and growing middle class is not a natural phenomenon. The natural human condition is dirt-scratching poverty. But what is the sensible economic policy that raises wages for working people? Is it by decreeing the minimum wage is $X? That is economic policy, but it is not sensible. Work that can't justify the minimum wage will be automated. The goal is an economy in which people can support themselves (with the understanding that no perfect economy can exist). I can't support a push for an economic policy based in feelings that will not work. But attaching "income inequality" to the push for equal rights means fracturing the movement.

And universal health care. Opposition to what other countries do is not a wish for poor and sick people to die already. That every other industrialized nation does this does not mean they do it perfectly, or that they do not get free-rider benefits from the United States because we don't do it their way. It also does not prove it can be replicated here.

It's clear a push like this expects the result of yesterday's march to be the further implementation of a progressive political platform. That just takes a message that "women's rights are human rights" and makes it explicitly - and incorrectly - political. The coherence of the demand disappears.

Some of this I already know from experience with protesting and agitating for change. I've protested in sunshine and rain, in heat and cold. I've had people yell at me and I've had respectful conversations. It's a messy process with rewards and perils throughout. Along with, "I hadn't thought of it that way," there's disagreement and the "with us or against us" mentality within the group. I've seen people be right for unbelievably wrong reasons. It's a fringe rather than universal, but the fringe gets the attention. Did you see more of the peaceful protests from Friday or the smashing windows? And when someone encounters a group protesting what they haven't thought about or don't agree with, do they remember the person trying to convince them or the lunatics? What's more effective, "May I talk with you about genital mutilation" or "May I talk with you about genital mutilation and how vaccines cause autism and the one percent"? The former is principled in science and ethics. The latter is "I have a mishmash of agenda items and you need to accept them all." Putting human equality into a mix of progressive (or conservative) political policies is no different.

Maybe I'm wrong on thinking this is putting human equality into a mix of progressive political policies. It's possible, and if it's true, do you want to convince me or condescend to me? Whether I'm right or wrong, that's your choice.

For example:

I've seen so many men today screaming about rights for Islamic women and genital mutilation. I look forward to your march re: those issues!

Or do you guys only bring those issues up to try to de-legitimize someone else's voice?

And a sample response:

@JulieDiCaro I think we both know the answer to that question.

I've marched and written extensively on the rights involved. I get laughed at for it. I get screamed at. I'm told how disrespectful I am when I emphasize the principle³ involved. There's no curiosity that I maybe know what I'm talking about from research and experience. I don't hold the right view, so my opinion should be mocked.

The same condescension is in those tweets. Maybe one/some/all of these men know? Or maybe they're all awful people merely trying to change the subject. It's probably the latter. Probably.

I composed a reply on Twitter but deleted it because 140 characters wouldn't convey the message. Ms. DiCaro is saying "Don't hijack the moment." I agree with that sentiment but not the delivery. For example, I don't jump into discussions purely about female genital mutilation to say "what about men?" unless the discussion includes crackpot opinions presented as fact or shoddy wishing masquerading as a principled defense of why girls deserve protection and boys should be happy about circumcision. But if you really want equality, "my body, my choice" applies to boys, or it can mean "my child, my choice" applies to girls. If you don't stand for principle, don't be shocked if it leads where you don't want to go.

Anyway, my point is that protests lose focus. They work against uniting a coalition on shared principle, preferring to enforce ideological rigidity. Yesterday's march and what follows can be principled. It won't be. There were speakers yesterday advocating for equal rights who also support male genital mutilation. Some rights are more equal than others, somehow, which will probably become generalized into the platform, so do not be surprised when this movement collapses into an incoherent, powerless mess without the necessary vigilance to adhere to "women are human beings deserving equal rights". Prove me wrong, please.

Post Script: Damnit, I realized I didn't talk about nazis yet. I've rambled enough, so I'm not going to work this into the above. Fucking nazis are evil scum. Don't sucker-punch evil fucking nazi scum. Because it's dumb and counter-productive and escalates into more violence. Yes, Hitler. But a street corner in Washington, DC on January 20, 2017 is not Omaha Beach. Maybe it will be if we don't challenge President Trump's administration every second until 1/20/21, 1/20/25, or his impeachment. But we're not there today. Not sucker-punching evil fucking nazis is not appeasement. Sucker-punching nazis is closer to the definition of conceding principles in favor of political expediency. That isn't righteous. That's a different form of authoritarianism. And if you want to require this fight continue until 1/20/25, sucker-punching nazis is a great way to create the lawlessness excuse Trump wants in order to make that a reality.

¹ Power expects compliance from everyone, not just women. This is why emphasis on "patriarchy" is so weird to me. I've yet to encounter an instance of someone saying "patriarchy" in which saying "power" wouldn't be more precise. I'm open to explanations and/or scenarios for why that isn't true.

² Destruction of property is violence. Someone has to clean it up. Someone has to pay for its repair or replacement. That requires work, so destroying someone's property necessarily involves forcing someone to do something they wouldn't otherwise need to do. It is force.

³ Non-therapeutic genital cutting on a non-consenting individual is unethical. All human beings are equal, with the same rights. I'm a feminist, including on that principle. But some feminists don't believe this right is equal. So sure, I'm a feminist, but the label isn't enough for me to know that we agree on human rights.

February 07, 2015

Teaching through condescension doesn't work

I love stuff like this, "16 Questions For Men That Reveal The Casual Sexism Women Experience Every Day", in the sense that I despise it. Human interaction is messy and too often hideous. That isn't a shaky limb to walk on. However, in my experience, "gotcha" as a teaching tool is unlikely to convince people who don't already agree. It is built on challenging smug assumptions by making its own smug assumptions. It strengthens defensiveness rather than opening doors.

The list opens with this (links omitted):

Sexism can be hard to point out when it's so engrained in our everyday lives. Clementine Ford, however, found an awesome way to highlight casual sexism with a simple hashtag.

Even though I disagree with the tactic, which is mostly (but not entirely) on how Huffington Post packaged these questions, the goal of challenging sexism deserves answers. First, the two tweets from Clementine Ford that kicked this off:

Question to the male writers/speakers etc out there. Is it common for you to be called an ‘attention seeker’? Or do just women get that?

A: Common? No. Men and women have told me this in debate, though.

#QuestionsForMen: When you have a hostile disagreement with someone, is it common for them to say you’re angry because no one will fuck you?

A: Common? No. Men and women have told me this in debate, though.

And 16 of Huffington Post's favorite #QuestionsForMen tweets (source article has the links):

Q1: Have you ever been told your business ideas are cute? #QuestionsForMen

A1: No.

Q2: #QuestionsForMen Are you comfy with the federal government & Christian conservatives holding decision making parties in your "boy" parts?¹

A2: About that... This routinely happens with "boy" parts. So, no, I am not comfy with others holding decision-making parties for my "boy" parts. Yet, others already made my decision.

This question is why the smug, closed-mind "gotcha" approach is stupid. You want me to think outside the box² you think I'm in? Think outside the box your question shows you're in.

Q3: #questionsformen do you walk home with your keys placed in between your fingers? are you constantly looking over your shoulder?

A3: No.

Q4: @clementine_ford #QuestionsForMen how often do you have to fake laugh at stupid/cringey/creepy/sexist things older men say regarding you?

A4: I've experienced those comments based on me being a ginger. I doubt the things said were as stupid/cringey/creepy/sexist as what is said to women.

Q5: #QuestionsForMen have you ever been late to work because you've had to change streets 5 times in 5minutes to avoid being catcalled by women?

A5: No. Again, I have had people bother me with rude things about being a ginger as I've walked. But I doubt the things said were the same. Nor has it happened a lot.

Q6: Do women jump into your face calling you fat, ugly, or that you "should get raped" for expressing an opinion online? #questionsformen

A6: I've been called names equivalent to fat and ugly for expressing an opinion online. I have not had threats of violence, sexual or otherwise. I have witnessed (and challenged) threats of violence against women and their children for expressing an opinion online.

Q7: #QuestionsForMen When out having a few beers, have you ever said "no" to a woman & then been hassled by her for the rest of the night?

A7: No.

Q8: #questionsformen In a job interview have you ever been asked how you will juggle work and home?

A8: No.

Q9: Do you get told 'you'll change your mind eventually' when you say you don't want to have children? #QuestionsforMen

A9: No. I have been told I should be thankful to my parents for having me circumcised as a healthy infant, even though I oppose it for myself. Similar in the sense that my opinion about myself isn't relevant to what society may expect of me?

Q10: #questionsformen anyone not hire you on the basis of "you're a man - you'll be having a family soon and need to devote time to that." ?

A10: No.

Q11: Do you send your mates a message to let them know you've gotten home safely? #questionsformen

A11: No.

Q12: If you take a leadership position, do you worry about being seen as bossy? Are you called bossy? #questionsformen

A12: No. No.

Q13: #questionsformen when you achieve something great, do you expect the female reporter to say, 'give us a twirl, who are you wearing?'

A13: No.

Q14: #QuestionsForMen Have you ever been basically told that going home with a woman means that she’s entitled to rape you?

A14: No.

Q15: @clementine_ford #QuestionsForMen How often are you expected to provide an explanation for why you didn't change your name to your wife's?

A15: Never. (My wife didn't take my last name. I couldn't care less.)

Q16: Have you ever had a coworker refer to you as sweetheart? #QuestionsForMen

A16: In the context implied here, no.

Sexism exists. In many ways it's systemic. We need to fight it. I don't have all the answers on how. I'm not perfect. I'm paying attention.

**********
¹ This person responded to someone who answered the question with the same point. She wrote:

[@...] Circumcision is NOT in a federal or state law book as a mandate, but is rather a parents' religious or cultural #choice.

This is how to miss the point, to be inside the mental box the original question demonstrated. 1) Why should a boy care whether it's his parents or his government imposing non-therapeutic genital cutting without his consent? 2) The state violating a child's rights is bad. The state permitting parents to violate a child's rights is also bad. And looking the other way matters when Congress (and states) legislated that "parental choice" is gendered. 3) Read the BBC link from my answer above. A German court found circumcision to be a violation. The German Bundestag, with support from Chancellor Angela Merkel, passed legislation to permit circumcision to continue. Twenty members of Congress publicly supported this.

The only valid choice (i.e. #choice) involved in circumcision must be the individual who would be circumcised. This "gotcha" needs rethinking.

² I'm not saying I'm outside (or inside) that box. I want to deal with this honestly. I think I'm good at not perpetuating sexism. I don't assume I am to the point I don't need to consider it regularly.

August 18, 2013

Today's Duh: Anthony Weiner is not a libertarian

In the true spirit of Kip's truth that all politicians are moral defectives, we have Anthony Weiner. When asked about the New York City health department's (weak) effort to regulate metzitzah b'peh, a ritual that has led to herpes infections that have killed at least two infant males and left at least two more with brain damage, Weiner said:

"You know, I've been criticized a lot of places for my position on metzitzah b'peh, on the ritual bris," he said last night. "My instinct as a liberal is the libertarian sense of that word, is that we have to be very, very careful when we in government decide to step in, even if we're 100 percent sure. Remember, government always is about the rule of the majority. ... You have to be extra careful to protect the rights of people that are in the smallest of minorities."

Anthony Weiner doesn't understand his instinct. He is not a libertarian. His position is not libertarian. Even the health department's inch-high speed bump (i.e. a "consent" form) is not liberatarian on this issue. That is not because it has the government stepping in, but because it does almost nothing. As practiced today, metzitzah b'peh - and child circumcision, more generally - violates basic human rights. There are dead and brain-damaged children already. The same risk exists in every instance in which it's performed, just as objective harm results from every circumcision.

Libertarianism recognizes the primary purpose of any legitimate government to protect the rights of its individual citizens. This includes the individual's right to bodily integrity and autonomy. Hence, valid laws against all other forms of non-therapeutic, unwanted physical violence exist without contention. Since children are also people, an obvious fact that too many self-proclaimed libertarians miss, government may enact and enforce laws to protect their rights, too. This includes protecting children from objective physical harm inflicted for reasons unconnected to objective need. Without need, the individual must consent. Proxy consent forms for objective harm do not protect children. They are not an acceptable standard. The libertarian position on non-therapeutic child circumcision is prohibition, as any other form of unwanted, unnecessary objective harm is prohibited.

Weiner manages to provide some insight in his words. The smallest minority is the individual, and the most vulnerable smallest minority is a child who can't defend himself. We have to be extra careful to protect them. That includes not being too cowardly to acknowledge something we're 100 percent sure about. Oral suction of an open wound is unsanitary and should only be done with the individual's consent. Ritual or "medical" circumcision of a healthy child removes normal, functioning tissue and should only be done with the individual's consent. There is no parental right to this rite.

Link via Janet Heimlich.

February 17, 2013

MRAs Are Probably Wrong, Except When They're Right

I understand why "men's rights activists" give some people heartburn. In too many areas it's warranted. I've written about examples before, and sided against arguments associated with the MRA argument. I prefer to have facts incorporated into my theories on how the world should be.

Male circumcision is one of the (possibly few) areas where the men's rights movement has truth¹ nailed down on its side. Male circumcision, as it's commonly practiced on healthy minors, violates the male's rights. Where anyone, including an MRA, shoe-horns it into a discussion of female genital mutilation, rather than discussing it if it evolves in a discussion, I understand and agree with the criticism. That's bad marketing, at least. I've probably done it, although I think I've learned where raising the comparison makes sense. I strive for better awareness. But the more common argument seems to be that the comparison is wrong, and men's rights activists shouldn't try to make it.

For example, Rational Alice started a series of posts on "the most common raisons d'être of the men's rights movement". The series starts with male circumcision:

This first topic should be quite an easy one. I'm taken to believe that it's not even very popular with the men's rights movement itself, though it is definitely present therein.

I'll argue here that male circumcision is "quite an easy one", but that Alice misunderstands the direction in which it is easy. My caveat is that I don't consider myself a men's rights activist. (Note: Links removed, unless necessary. Emphasis in original.)

Those MRAs who take circumcision as one of their issues of choice assert that "male" circumcision — that is, the removal of the foreskin of the penis — is on par with "female" circumcision, or "female" genital mutilation, and is not being adequately addressed as a problem by those who campaign against it. I.e., they decry the fact that male genital mutilation is not seen as a problem by the public, while female genital mutilation (or genital cutting, FGC) faces enormous opposition; i.e., society cares more for the treatment of women's genitalia than men's.

First, I'm going to acknowledge my ignorance. I have no idea why male and female are in quotes. I assume it involves cis- in some form. If so, it's odd to debate this from identity when it's better resolved through basic anatomy intersecting with human rights. The world is more complicated than "boys have a penis, girls have a vagina," but the principle incorporates women who have a penis, men who have a vagina, or men and women who have both.

That principle is easy to state. Non-therapeutic genital cutting on a non-consenting individual is unethical. Or, to put it in narrower words for the comparison: removing the healthy prepuce of a non-consenting individual is unethical. There are more complex issues within this topic, but that gets to the direct anatomical comparison within a framework that views all people as possessing equal rights. Any view that veers from that to distinguish between acceptable and unacceptable non-therapeutic genital cutting without consent is wrong.

As for the charge that opponents of female genital mutilation don't adequately address male circumcision, I don't expect anyone to expend energy on subsets of a topic that don't interest them. Focus on female genital mutilation. All I expect is that a person not defend contradictions. If someone is an activist against female genital mutilation, that's great. The world needs dedicated people to help end FGC/M. If that person also defends male circumcision as commonly practiced on minors, that person is a hypocrite. Don't be a hypocrite. That's my only demand.

After a paragraph on tradition:

The universal standard advocated by MRAs is not so different from what is advocated by a great number of progressives: that no infant's genitalia should be altered without their consent, which they obviously cannot give, except for immediate medical concerns (and the topic of intersex genital assignment is one for another post). What makes it MRA-specific, then? Well, simply the fact that they believe the activism surrounding FGC demonstrates social discrimination against men, and not, as many would have you believe, the facts about the actual procedures of FGC compared to that of "male" circumcision.

I disagree with this assessment. Perhaps men's rights activists perceive the problem as "the activism surrounding FGC demonstrates social discrimination against men". I doubt it, and Alice provides no example. (The reason is in the post's introduction.) I suspect men's rights activists do not like having their valid concerns over male circumcision dismissed, not what that dismissal symbolizes. Reality demonstrates how society, through law, treats genital cutting unequally based in gender. Disregard for the obvious similarities between female and male genital cutting is the problem that helps allow inequality to continue.

A campaign against (forced) female genital mutilation is not unfair or discriminatory if it doesn't address (forced) male circumcision (i.e. genital mutilation). A campaign against forced female genital mutilation is unfair and discriminatory where it addresses forced male circumcision and dismisses it or deems it acceptable, for whatever cultural, religious, or prophylactic reasons might be cited.

Again, the principle is universal. It isn't male versus female, or "male" versus "female". All human beings have the right to their own healthy, intact genitals, in whatever form that might take, until they may decide to alter them. If a basic human right does not apply to all humans equally from birth, then rights are a worthless concept that serve no purpose beyond being an ideological tool. No.

To that point, let's talk about FGC. There are four types: Type I involves removal of the clitoral hood and the clitoris; Type II involves removal of the clitoris and the inner labia; Type III involves removal of the inner labia, the outer labia and the clitoris, followed by fusion of the wound — which is only opened for intercourse and childbirth; and Type IV covers various less-severe practices like widening the vagina and piercing the clitoris. Think about all that for a while. ...

I agree with Alice's summary here, although I'll add that Type IV is generally considered to be "all other harmful procedures". That's broader and more useful. (The four types are described in the WHO fact sheet on female genital mutilation.)

The U.S. Female Genital Mutilation Act of 1996 (18 USCS § 116) criminalizes all non-therapeutic genital cutting on female minors without regard for parental justifications "as a matter of custom or ritual". That includes any genital cutting equal to or less harmful than male circumcision. There is no defense to be made for genital cutting on male minors if equal human rights are to matter, barring one's support for repealing 18 USCS § 116 and all similar laws. That would be inexcusable, but it would at least be consistent.

... What does the foreskin do for the penis? Homologous to the clitoral hood, the foreskin evolved to protect the end of the penis. Recent studies have revealed no significant difference in sexual sensation between circumcised and non-circumcised penises. ...

That study is from January 2004. This study, which "confirms the importance of the foreskin for penile sensitivity, overall sexual satisfaction, and penile functioning", is from February 2013. It's illogical to assume that removing part of the penis would have no effect on sexual sensation. But, if only the study Alice presents is correct, so what? Sensitivity is an issue, and I'd argue that changing the functioning (e.g. removing the foreskin's gliding motion) of the penis is enough to argue against forced circumcision. What does the individual want? The issue is self-ownership and bodily autonomy. Do we own our bodies (i.e. our genitals)? The accepted position here is that females too often don't but always should, while males don't and that isn't an issue. That distinction is absurd. Calling it out for criticism and change is appropriate.

... (As a matter of fact, circumcision is recommended by the WHO as part of its program on preventing HIV infections, as risk of acquiring HIV through heterosexual intercourse goes down significantly after circumcision.)

The studies found a reduced risk of female-to-male HIV transmission in high-risk populations from voluntary, adult circumcision. None of that describes the United States or Europe, and the key in that specific scenario — voluntary, adult — doesn't apply to infants in Africa. Male circumcision in the context of Alice's post is a different ethical issue than what's in the parenthetical. This is often the problem. Mixing it all into one simplistic idea leads to mistaken conclusions.

Removal of the foreskin is not so different from reduction or removal of the clitoral hood, which is a component of Type I FGC. But consider the homology of the labia majora and the scrotum, and of the clitoris and the penis. These are essential components of "male" sexual physiology. Not only is FGC exceptionally cruel, ...

It's inappropriate for one person to tell others what is an inessential component of their bodies in the context of what is - and isn't, allegedly - cruel to permanently force on them without need or consent.

... "male" circumcision cannot even come close to the cruelty inflicted by removal of the clitoris and/or the labia. ...

That's the "heads I win, tails you lose" approach to the comparison. The homology of the female and male prepuce is the consideration, the "not so different" Alice used to start the paragraph. Removing the former by force is illegal. Removing the latter by force is encouraged. That's the flawed disparity. Criticizing MRAs is often appropriate, but here the facts are on their side, if not always their methods.

In the larger argument, removal of the clitoris and/or the labia is worse than removal of the male prepuce. That isn't much of an insight. It's easy to acknowledge that FGM is evil, because it is. It's possible to accept that FGC/M is almost always worse than male genital cutting (dare I say, mutilation) in outcome, as commonly practiced. Neither of those excuse forced male circumcision. A knife to the gut is worse than a punch to the face. Should we permit the latter because it's less damaging? Are we indifferent to any assault worse than another? Will we establish a tournament to find the one form of assault that's bad because it's the worst? it's a preposterous argument. Real differences exist in the practices. That should inform criminal punishment, for example, without providing legal or cultural cover for lesser forms of forced genital cutting.

... It is a blatantly misogynist — and also, quite plainly, wrong — argument to say that the two are even remotely comparable, or that the campaign against female genital mutilation is unfair and discriminatory because it doesn't address male circumcision.

Comparing the two isn't misogyny. There is no hatred of females or belief that women are less than males. Someone's strategy could involve misogyny, or confuse silence with discrimination, but that's not the comparison, which is rooted in principle and facts. Non-therapeutic genital cutting on non-consenting females must end where it occurs. At the same time, non-therapeutic genital cutting on non-consenting males must end where it occurs. The comparison exists without lessening females or what is done to them. Non-therapeutic genital cutting on a non-consenting individual is unethical. That's the core.

¹ Consider something like conscription. Should women be forced into conscription to be equal with males, or is this an area where the rights of males are violated? (Or the requirement to register for possible conscription that also only applies to males?)

October 12, 2012

310 Million Individual Nations

Author John Green hates Atlas Shrugged with a White-Hot Passion. I don't mind that he doesn't like the novel. All tastes and preferences are unique to the individual, after all. But that's also the flaw in his analysis.

He writes:

1. Atlas Shrugged is a novel of ideas. The plot exists only so that Ayn Rand can lay out her set of philosophical beliefs. So it’s the kind of book that makes you feel smart because you “get it,” but the story itself is paper-thin and is carefully constructed to explain and celebrate Rand’s objectivism. I have an inherent problem with novels of ideas, because I think they fail to do most of what is interesting and useful about fiction, but I particularly dislike them when the ideas are bad ideas.

I am not an Objectivist. I recognize common ground with it but am not particularly fascinated by the label. I also agree with his assessment of Atlas Shrugged, to a small degree. Rand was hardly a perfect novelist. And I don't like novels of ideas that are about bad ideas. But Atlas Shrugged is not about the idea Mr. Green thinks it is.

2. The philosophy of objectivism is absolutely repugnant to me (and also does not hold up to scrutiny). The philosophy of selfishness is all built around the idea that the person ingesting the philosophy feels special (i.e., that we all identify with John Galt), and of course we do all identify with John Galt, because we all feel that the world is against us and we are secretly a unique flower that could bloom brilliantly if only we did not have to carry the weight of other, lesser people.

The "philosophy of selfishness" is accurate enough as a descriptive term, but not when we use the word selfish as the pejorative in common meaning. The novel doesn't push the idea it's so often accused of endorsing. It isn't an ode to "Fuck you, I've got mine". Selfishness in a Randian view is compatible with all sorts of actions associated with altruism. The difference is force. The unrequited correct form of altruism inspires force to achieve this correct form on the odd belief that humans would devolve to "Fuck you, I've got mine" if not for this push of force.

Or, as Timothy Sandefur explains more eloquently in his response to a straw-man attack on Ayn Rand in Slate:

Slate proclaims that evolutionary psychology shows that Objectivism is wrong because evolution favors “altruism,” which the article question-beggingly defines as “helping others.” Of course, Rand never claimed that helping others is wrong. What Rand said was that you do not live for the purpose of making other people happy. There is a big difference. Objectivism has always held that there are often perfectly good reasons to help others who are of value to you. And what evolutionary psychology actually shows is that Rand was on solid ground making that claim. What the evidence shows is that humans (and other animals) often help those who are close kin to them or are in a position to help them—so-called “reciprocal altruism.” The confusion arises because the term “reciprocal altruism” is a contradiction: if it’s reciprocal, it’s not altruism. I defy anyone to show me where Rand said that “lending a helping hand” is a bad thing.

(The rest of Mr. Sandefur's post is worth reading.)

Personally, I donate money and a considerable amount of my time for a cause from which I will never personally achieve the benefit I advocate. My efforts can benefit others. I do it because it's the right thing to do. But here's the thing that separates this from the mistaken idea presented in Mr. Green's analysis. I put my money and time into this specific cause because it's what I care about. My efforts help people, but at the core, I am being selfish. Should I therefore stop?

I have also been told many times that there are "more important" issues to deal with. Perhaps. How effective do you think I'd be toiling away on a task that matters only in the abstract nature of altruistic sacrifice? I'd punch the clock for my obligation, and not for very long, rather than think and write at all hours and travel the country and stand in cold rain during protests. I value what I'm doing and why I'm doing it more than the costs.

I don't feel the world is against me, either. Badly mistaken in critical ways, yes, but there is no conspiracy. We don't live in a perfect world.

But the fact that when we read Atlas Shrugged we all identify with the elite is itself evidence of the book’s crappiness, because either A. only extraordinary people happen to read Ayn Rand, or B. we all feel extraordinary, because we are so busy being our multitudinous and complex and extraordinary selves that we do not imagine other people as being as complex or interesting or extraordinary as we are.

I suspect everyone who reads Atlas Shrugged identifies with the heroes. (Or misunderstands which characters are the heroes?) But this isn't the fault of the book. The people who identify with the heroes who are like the villains are wrong in their self-awareness and understanding. This is not a critique of the book's underlying idea. When Dustin Brown tried to drink from the wrong end of his water bottle, did that indicate a mistake in the design of the water bottle?

We all act selfishly. This is not bad. The world would not devolve into chaos if we recognized this. "Good" will still occur. It is human-nature, and should be celebrated.

If I could find my copy, John Green's The Fault in Our Stars contains this correct notion of selfishness in its characters' actions. Regardless, I recommend the novel. It's a fantastic story.

August 27, 2012

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.

August 23, 2012

Liberty, But Only If Your Parents Let You Have It

I have no problem with the label libertarian, even when it's conflated with the Libertarian Party. I have a problem with being associated with what passes for thinking on the rights of children among too many self-proclaimed libertarians. Somehow the libertarian view for so many shakes down to something equivalent to children as parental property. This is most easily seen when the topic turns to male circumcision. So it is again. In response to charges filed against a rabbi/mohel in Bavaria following the recent court decision in Cologne declaring that non-therapeutic circumcision of a child violates the child's rights to physical integrity and self-determination, Doug Mataconis writes at Outside the Beltway (links in original):

There’s also been a bizarre movement growing against circumcision itself here in the United States and in Europe. Just last year, for example, a referendum that would’ve banned circumcision in the City of San Francisco was scheduled to appear on the November 2011 ballot before being removed. The motivations for this version of the anti-circumcision movement seems to be something similar to what the Judges in Cologne stated, that it was some kind of assault about a party who is unable to grant consent. ...

Surgically removing a normal, healthy, functioning body part from an individual who does not consent should be recognized as battery, yes. That is not bizarre. It's merely extending the usual rational standard for non-therapeutic surgical intervention on healthy children to male genitals.

... Andrew Sullivan, for example, contends that infant circumcision is an assault on infant boys. Left out of the argument, though, is the fact that parents have been long assumed to be able to competently make medical decisions for their minor children. ...

Except there are limits, including a specific limit on the option for parents to make "medical" (i.e. non-therapeutic) surgical decisions for the genitals of their minor children. USC § 116 - Female genital mutilation clearly establishes conditions upon which we ignore this alleged competence. If non-therapeutic genital cutting falls within the realm of making "medical" decisions for a child as a parental right, then 18 USC § 116 infringes on this supposed parental right. If this is about parental rights rather than individual rights, the child, whether male or female, would be irrelevant to the law. It isn't. It's about the harm to the child. Section (b) makes it clear that all non-therapeutic genital cutting on female minors is illegal, including any cutting analogous to or less harmful than male circumcision. Section (c) demonstrates that no parental justification will be accepted for this intervention on their daughter(s). The primary consideration becomes whether or not male circumcision is harmful, not this:

... Leaving that argument aside, I would think that any ban on circumcision in the United States would, because of the First Amendment, have to include an exemption for Jews and Muslims who consider the procedure a requirement of their religion.

Because boys don't have the same basic human rights as everyone else, at least for the physical integrity of their normal, healthy genitals? Eugene Volokh's parental and religious rights posts during last year's San Francisco ballot initiative identifies a plausible response to this. Again, the correct question is whether or not male circumcision is harmful, not why parents might choose it for non-therapeutic reasons.

On the question of harm, the evidence is quite clear. Circumcision inflicts harm every time. The individual loses his foreskin. He has nerve endings within his penis severed. He may lose his frenulum. He will have a scar. There is also the risk of complications. Some males will suffer those, and some subset will suffer horrible outcomes. The mortality rate from non-therapeutic child circumcision is very low, thankfully, but it isn't zero. Treating individuals as statistics is hardly a libertarian position.

Next, he quotes an ad hominem attack by Jonathan Tobin:

Circumcision opponents may claim they are not anti-Semitic, especially since their campaign also targets Muslims. But there is little doubt that the driving force behind this movement is resentment toward Jews and a willingness to go public with sentiments that long simmered beneath the surface in Germany and elsewhere in Europe.

Just last week, French scholar Michel Gurfinkiel wrote on his blog that anti-Semitism has increased in France since the Toulouse massacre in March. Since then violence has grown, fed by what he calls a rejection of Jews and Judaism. In France, these sentiments are fed by the Jew hatred openly expressed by the expanding Muslim population. Throughout Europe, the demonization of Israel hasn’t just increased hostility to the Jewish state; it has served as an excuse for anti-Semitism to go mainstream for the first time since World War Two. Just as some claim circumcision critics aren’t intrinsically anti-Semitic, there are those who blame anti-Semitism on Israeli policies. But when you add all these factors together what you get is an undeniable upsurge in Jew-hatred.

There is significant doubt that resentment is the driving force. I won't speak for Germany, although I think the court's ruling was not based in religious animosity. The ethical human rights-based case against non-therapeutic circumcision exists on its own. It's clear, based in the basic rights to physical bodily integrity and self-determination. The ability to find instances of anti-Semitism does not discredit that case or the general movement to restrict non-therapeutic circumcision to those who choose it for themselves. Where anti-Semitism occurs, and it unfortunately does, it discredits the individual purveyor, not the movement as a whole. And such instances should be denounced without ad hominem against anyone who shares only an opposition to non-therapeutic circumcision on non-consenting individuals.

Mataconis' response to Tobin's charge:

If that’s true, then it is a quite troublesome development. Even leaving this element out of it, though, there’s something troublesome about this entire affair. Circumcision has been an accepted practice in Western societies for centuries ...

That's interesting but proves nothing. History provides plenty of examples of rights being violated for a long time. The rights are no less violated. Non-therapeutic circumcision constitutes guaranteed physical harm to the child in pursuit of his parents' preference(s). It's the objective versus the subjective.

... and, in the case of two religions, it isn’t just an elective medical procedure, it is a requirement of their faith. ...

Being a requirement of Judaism and a recommendation in Islam are relevant, but they are not the first question in this context. The circumcision is being imposed on someone. It's an odd conception of freedom that says imposing surgery on someone else is an individual right within religious freedom. Under the proposed public policy stance, religion would have to adapt. That expectation is no different from the numerous declarations in religious texts that we do not permit in civil law. Religion deserves no special exemption. The protection required is for individuals to choose circumcision for their own bodies, not for others.

... The arguments of the circumcision opponents strike me as being little more than ridiculous nonsense that, for some, has turned into some kind of weird cult of the foreskin. As far as I’m concerned, parents are perfectly capable of making this decision for their sons and the state really has no business getting involved in at all. When you bring the element of religion into it, state interference becomes even more problematic. One would hope that the government in Berlin will intervene and put an end to the nonsense that the judges in Cologne started.

Non-therapeutic genital cutting on a non-consenting individual violates basic human rights. That isn't ridiculous nonsense. We apply it completely to females. We don't apply it to males. Instead, it's easier to smear with words like cult and fetish. Fine, if that's the standard, we should start telling activists against female genital cutting/mutilation that they're spouting ridiculous nonsense that is some kind of weird cult of the clitoris? We wouldn't because there we recognize the facts. With circumcision we forget to apply the same standard that protects the property interest of the individual. For reasons. That makes no sense.

It's certainly not within a reasonable understanding of libertarianism. For anarchists, sure, opposition to the state becomes the overriding goal. But if one assumes a state to be legitimate with a specific interest in protecting the rights of its citizens, then it's legitimate for the state to prohibit this form of possibly unwanted harm. That is the approach that recognizes humans rather than statistics. (To hope that politicians will step in to reverse a judge is a foolish action to endorse.) Parents don't just circumcise their sons. They effectively circumcise the autonomous adult he will become. Proxy consent based on anything other than clear medical need is insufficient to permit that.

**********

Post Script: In the comments to his post, Mataconis responded with a standard trope:

Fine. Then if you have a son, don’t get him circumcised, that’s your choice.

Treating children as property is not libertarian. The correct formulation is "If you don't want to be circumcised, don't have yourself circumcised". That's the method to protect individual preferences, not the illegitimate force of individual preferences on another. Shared DNA is not a defense.

That flows into a later comment:

What is the medical benefit the foreskin provides?

To the silly question, it protects the glans and provides sexual sensitivity. But let's assume neither is true. "It's mine" is sufficient. The onus is not properly on the person who doesn't want his property taken to explain why his property shouldn't be taken. Or, at least, that's what I thought libertarians believed.

June 30, 2012

The ACA and the Future of Infant Circumcision

I've made the argument that a government-run single-payer health care system in America would not automatically result in non-therapeutic infant circumcision rates comparable to other Western nations (e.g. United Kingdom), probably most directly here. I stand by that for the reasons I've stated. But now that the Affordable Care Act has been upheld by the Supreme Court, I want to explore a possible (though unlikely) unintended consequence of encouraging the government to control more health care.

As I understand it, the government has now been given what amounts to unlimited power to incentivize (i.e. compel) activity to achieve a public policy goal where some (or many) may prefer inactivity. Congress merely needs to establish a "Do X or Pay T" regulatory scheme. Many, although not a majority of Americans, approve of this for health care. This is presumably a statement on the value of the goal rather than an explicit endorsement of the means. But the means matter.

Extending this thinking, what now prevents the Congress from implementing "Circumcise your newborn son or Pay a Tax"? It now has that power. And the logic is no different. Congressman Brad Sherman endorsed the political thinking that would encourage such a policy during last year's discussion of the San Francisco ballot initiative. He declared that "Congress has a legitimate interest in making sure that a practice that appears to reduce disease and health care costs remains available to parents".

I do not believe this is politically likely. With any extension of this newly-expanded power, Congress will need the political cover to pass a new tax. They swore the ACA wasn't a tax, though, so lying is an option. They're politicians, after all. It would still face challenges. But it is possible, and we've seen the lengths to which politicians will fall over themselves to avoid offending the status quo on non-therapeutic infant circumcision.

I think my argument holds up. If nothing else, the ACA almost certainly slows future progress on ending this violation of male children. Cultural circumcision has a new god in the perceived¹ reduction in future health care costs. There are means available within government control to pursue that. If we get further "reform", it's likely to offer even more control to the government. That is a problem. This seems obvious to me. As long as the government has a power and a willingness to ignore facts, the possibility of consequences exists, both intended and unintended. We should be careful which methods we endorse.

**********

¹ The time value of money must be included. A dollar spent today on health care is not the same as a dollar that might be spent twenty, thirty, or more years from today. The number of adult circumcisions needed would have to be greater than it is to justify this public purse argument. It still wouldn’t be ethical to circumcise healthy infants, of course.

June 27, 2012

Accountability to Those Who Pay the Buck-O'-Five

Ken at Popehat has a perfectly concise take-down of LZ Granderson's ridiculous CNN essay arguing against seeking too much information from our government about "Fast and Furious". I won't be able to say it better than Ken, so here are his words. (And if you're not reading Popehat, correct that in your RSS reader.)

But to go much beyond the criticism of these men runs the risk of learning that this great nation of ours is heavily involved in doing some things that are not so great.

It would be nice to see this as a wry comment on American willingness to overlook lawbreaking by the government when it is committed (at least nominally) in service of goals of which we approve.

But the straight-faced reading is too similar to what I have come to expect from the media to be certain of my hoped-for satirical reading. Right now scandals over both Fast and Furious and the government response to it are being spun in many places as a cynical partisan obsession. I have not the shadow of the doubt that many of the loudest critics of the government have partisan motives. But if we dismiss criticism of government misbehavior because of partisan motivations, we'll never entertain significant criticism of the government. We'll always have partisanship. We can't let it be an excuse to abandon our obligations as citizens to monitor and criticize the government.

Like Granderson, I know that "freedom isn't entirely free". It's not "squeaky clean". Unlike Granderson, and like Ken, I expect America to strive to be as squeaky clean as possible. Where we (allegedly) can't be, I want to know why. I want to know what my government is doing in my name. I do not want elected dictators.

**********

LZ Granderson has exhibited questionable critical thinking skills in the past. A year ago he wrote an essay against the San Francisco ballot initiative that aimed to prohibit non-therapeutic male child circumcision. It was awful in nearly every paragraph. His arguments were either incomplete or idiotic in every case.

June 15, 2011

Congressman Brad Sherman Is Wrong On Circumcision

This is why I don't like the political process for ending non-therapeutic circumcision of male minors.

Congressman Brad Sherman announced today that he will be introducing the Religious and Parental Rights Defense Act of 2011, a bill to prevent San Francisco and other municipalities from banning the circumcision of males under the age of 18.

Sherman’s new bill is in reaction to a measure that has qualified for the November 2011 ballot in San Francisco that would make the performance of circumcisions on males under 18 a misdemeanor—with a possible $1,000 fine and one-year prison term.

He's framing the problem incorrectly, which allows him to protect a "right" that doesn't exist and ignore a right that does. The proposed bill in San Francisco would prohibit non-therapeutic circumcisions on males under 18. Healthy children do not need surgery, even if the parents' god says so. California law already restricts the rights of parents to cut the healthy genitals of their daughters for any reason, including religious claims. Is that an infringement? Of course not. Likewise, there is no First Amendment right to inflict permanent harm on one's children sons (only).

Sherman expressed concern over the motivation of the provision. “To infringe the religious rights of so many Americans, San Francisco should have some compelling medical reason; however, the medical literature actually shows clear benefits of male circumcision.”

The provision, shown by its generally-applicable wording, would protect the right of all healthy males to keep their normal body intact and free from the objective harm of non-therapeutic surgery to which they do not consent. It's the same right U.S. and California law protects for their sisters. That right is being violated. It must stop. This is a way to achieve that, even if it may not be the best way.

But if we incorrectly assume this infringes a legitimate religious right, San Francisco (and every other locality) has a compelling medical reason to prohibit non-therapeutic male child circumcision: it's non-therapeutic genital cutting imposed on a non-consenting individual. The healthy child does not need circumcision any more than he needs an appendectomy. If he has an appendectomy, he will never get appendicitis. That is a potential benefit. Should we therefore allow parents to have a surgeon cut their healthy children sons (only) to remove his potentially harm-producing appendix? In the name of parental rights? No, because that would be stupid. The ability to chase some possible benefit can't be an ethical justification to perform an invasive, unnecessary surgical intervention on a healthy child.

Congressman Sherman added:

“Congress has a legitimate interest in making sure that a practice that appears to reduce disease and health care costs remains available to parents,” Sherman said. “And, nothing in my bill prohibits statewide law ensuring that male circumcision occurs in a hygienic manner.”

To the extent that Congress has a legitimate interest¹ here, it's in protecting the individual rights of every citizen, including male children. It already protected female children with the Anti-Female Genital Mutilation Act of 1996. That prohibits non-therapeutic genital cutting on non-consenting female minors for any reason, including religious claims by the parents. Does that infringe on parental religious rights? Are we illegitimately denying religious rights by not permitting other acts by parents sanctioned by various religious texts? Are the healthy genitals of male minors beneath the equal protection of the Fourteenth Amendment?

“Congress has historically legislated to protect the free exercise of religious rights from state and local intrusions,” Sherman said. “In 2000, Congress passed the Religious Land Use and Institutionalized Persons Act, designed to protect religious institutions from unduly burdensome local zoning laws.”

The logic of the law Congressman Sherman cites favorably requires the conclusion that his proposed bill is flawed. The Religious Land Use and Institutionalized Persons Act establishes that the government may not impose a burden

...unless the government demonstrates that imposition of the burden on that person, assembly, or institution--
(A) is in furtherance of a compelling governmental interest; and
(B) is the least restrictive means of furthering that compelling governmental interest.

(A) Protecting children from unnecessary, objective harm is a compelling governmental interest. Circumcision, as surgery, inflicts objective harm in every instance. When there is no offsetting medical need, the harm is the only guaranteed result. Preventing that is the premise behind prohibiting all female genital cutting on healthy female minors, even genital cutting that is less severe, damaging, or permanent than a typical male circumcision. The government recognizes that girls are individuals with rights that deserve to be protected. Infringing on a non-existent parental right to cut the healthy genitals of their daughters children is a legitimate state action.

(B) The least restrictive means would be for parents to understand that non-therapeutic genital cutting on healthy children is ethically and medically wrong and, thus, refrain from imposing it on their sons. Yet, religious and non-religious parents alike cut the healthy genitals of their sons. How else is the state supposed to stop it without exercising its legitimate police power?

Congressman Sherman should withdraw the Religious and Parental Rights Defense Act of 2011 immediately. He should also introduce a bill to remove the gender bias from the Anti-Female Genital Mutilation Act of 1996 to create the Anti-Genital Mutilation Act of 2011, if he's serious about using the powers of Congress correctly to protect the rights of all American citizens.

Update: More from Congressman Sherman:

Sherman said he did not consult the text of the Federal Prohibition of Female Genital Mutilation Act of 1995 in composing the bill he will put forth in Congress.

“I think people who make that analogy are so wrong that their thinking does not color my thinking,” Sherman said.

Since he's working with a closed mind, I'll simplify: non-therapeutic genital cutting on a non-consenting person is wrong. The extent of the damage is irrelevant. The reason cited is irrelevant. The gender of the victim is irrelevant. Non-therapeutic genital cutting on a non-consenting individual is wrong.

¹ I want to be proved wrong on this, but Sherman's statement is further evidence of my prediction that ceding power to the government on health care would lead to arguments that child circumcision provided fiscal benefits to the nation. It wouldn't change the ethical violation involved, but Congressman Sherman doesn't provide a cost-benefit analysis for his claim. Only in Congress can spending money always mean saving money.

June 12, 2011

Much Ado About Individual Rights

Timothy Sandefur links to essays by two secular humanists regarding the San Francisco proposal to prohibit non-therapeutic male child circumcision. The essay in favor of the proposal is by Tom Flynn of the Council for Secular Humanism. Mr. Flynn is correct. The essay against the ban is by Ronald Lindsay of the Center for Inquiry. Mr. Lindsay is wrong. I wish to address his essay.

Mr. Lindsay begins:

First, let’s cut through the misleading rhetoric. Some proponents of the ban refer to male circumcision as genital mutilation and equate it with female “circumcision,” the term sometimes used to describe a clitoridectomy, or complete removal of the clitoris. Clitoridectomies are carried out in some cultures, principally in rural Africa. (In some instances, not only is the clitoris excised, but the labia minora and parts of the labia majora are also removed.) Obviously, the removal of the clitoris results in loss of sexual pleasure.

To equate clitoridectomies with male circumcision is nonsense. The latter is a clip job, resulting in removal of the foreskin from the penis. ...

It is not nonsense. They are different in degree, not kind. Non-therapeutic genital cutting on a non-consenting individual is wrong. That principle is universal, not gender-specific or discounted if we can figure out some possible benefit. Anything becomes acceptable if we accept possible future benefit as a relevant standard for intervening on healthy children. Of course female circumcision genital cutting is mutilation. Western societies agree on that almost universally. We've demonstrated that understanding by enacting laws against any procedures involving the healthy genitals of female minors.

But Mr. Lindsay is incorrect in limiting his point to a comparison of male genital cutting (i.e. circumcision) and clitoridectomies. The latter is an example of FGM, not the definition of FGM. The scope of what qualifies as mutilation mirrors what is illegal in most locations in the United States, including California. The World Health Organization defines female genital mutilation as follows (emphasis added): "Female genital mutilation (FGM) comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons." In other words, any surgical intervention less damaging than male circumcision, inflicted for the exact reasons we cite for male circumcision, would still qualify as genital mutilation. Every one of those procedures (i.e. Types I - IV) is already illegal to inflict on healthy female minors. Applying the principle and rights in that accurate definition equally, non-therapeutic male child circumcision is genital mutilation.

After mentioning various possible risk reductions from male circumcision, Mr. Lindsay writes:

The foregoing medical discussion is important because it undercuts the argument made by some secularists that there’s no valid medical reason for this procedure. Granted, the possibility that a newborn boy will experience some avoidable health issues unless he is circumcised is very small. Furthermore, depending on how one evaluates the risks, the potential benefits may be outweighed by the risks of harm. But isn’t this precisely the type of decision we usually leave to parents — and which we should leave to parents unless we want to become even more of a nanny state?

To avoid confusion, any reason for circumcising a healthy male is non-medical. Again, if we are to pretend that chasing potential benefits counts as a medical reason for non-therapeutic surgery, then parents may impose any intervention they wish, unrestrained by society. Protecting children from that is not a nanny state action. It's the legitimate role of government to protect the rights of all its citizens, including male minors. We shouldn't need new laws here. But parents shouldn't mutilate their children.

Mr. Lindsay raises a legitimate question:

Speaking of the state, do we really want to give more power to the government to control what can only be described as a sensitive, highly personal matter? How exactly is this criminal ban supposed to be enforced? Are we going to have special police units to stamp out circumcision? Undercover cops posing as physicians willing to carry out back-alley quick cuts? Will there be search warrants issued based on confidential information that Johnny was seen at the urinal less than fully intact? I don’t know about you, but I don’t care if my junk is scanned or touched at the airport security line, but I do reject the notion that the government can tell us how it should look.

I agree that enforcement is a challenge. That assumes it would be enforced, which I don't believe would happen in the unlikely event it passes. Still, the question is relevant. What I think it would most likely do is provide better support for circumcised males to sue for the obvious battery inflicted. That's not everything, but it's something.

The biggest flaw in Mr. Lindsay's approach is the conclusion he draws. I care if my genitals are scanned or touched at the airport security line. Do my rights not matter because Mr. Lindsay thinks differently? Are individual tastes and preferences not unique to each individual?

While I also reject the notion that the government can tell us how our genitals should look, that isn't what this law would do. It would prevent parents from dictating how their child's son's genitals must look for the rest of his life. It would leave the individual male himself to say "yes" or "no" to non-therapeutic circumcision. I'm no more mollified that my parents mutilated me than I would be if my government had ordered it. The result is the same.

Later, he inadvertently proves that he misunderstands the issue:

I’m tired of secularists fighting the wrong battles. We shouldn’t care whether Johnny, Joel, or Jamal keeps his hood on.

I don't care whether Johnny, Joel, or Jamal "keeps his hood on." I care that he gets to choose whether or not to keep his healthy foreskin. The emphasis is on his and healthy, not foreskin. That's the debate, not this incorrect view that male circumcision is "a clip job" that may be imposed at the will or whim of parents.

Related post from 2008.

June 04, 2011

Opposition to Circumcision and Anti-Semitism: Follow-Up

Continuing on yesterday's post, I'd like to expand a bit with evidence. For context, consider this from a post at Hot Air Green Room on the Foreskin Man comic book:

Note that these circumcision-haters could have addressed the issue as one of science, medicine, personal autonomy, or even just a social issue on which reasonable people can disagree.

My archives demonstrate exactly that. But the issue is obviously larger than me, and currently focused on the proposal in San Francisco. The question is whether we're going to rightly hammer those involved in the creation of the Foreskin Man material for pushing anti-Semitic filth, or are we going to set aside logic and tarnish everyone opposed to circumcision who favors the plain language of the proposal, regardless of their demonstrated determination to engage the issue only as one of science, medicine, and personal autonomy devoid of anti-Semitism? Do we criticize and ostracize those directly involved or do we simply stop thinking altogether, ignore the issue involved and just self-congratulate?

To demonstrate what I wrote yesterday about my behind-the-scenes efforts, this is an e-mail I sent on December 3rd when I first encountered Foreskin Man issue #2. (I've omitted references to the recipient because, as I said yesterday, I don't wish to embarrass, if appropriate. Those involved rectified the problem immediately.)

To whom it may concern:

I do not believe [you] should be promoting the Foreskin Man issue #2 comic in any forum. The caricatures within this issue suggest that those of us against non-therapeutic infant circumcision can't see the difference between what is done and why it is imposed on healthy children. We understand the reality of circumcision and how parental intent does not justify or improve its imposition. But we must act against the procedure being forced on children without engaging in stereotypes and ad hominem. Issue #2 isn't close to being acceptable on those points.

We already encounter mindless accusations of anti-Semitism by people who refuse to engage in any critical thinking beyond the silly notion that challenging circumcision is an attempt to destroy Judaism. This charge is nonsense, but we are able to counter it with our words and deeds. The wording of the various MGM bill initiatives demonstrates this neutrality in seeking only that individuals choose for themselves, not the complete elimination of circumcision. Promoting anything the [sic] depicts "Monster Mohel" wielding machines [sic] guns and stealing children from parents who already don't consent to a bris for their son is damaging to us.

I am willing to give the benefit of the doubt, although I can only hope this was promoted because no one reviewed it before ... . Such an action wouldn't be acceptable, but it would be a forgivable one-time error. However, I will not be associated with this type of material or anyone who supports it. ...

Thank you for your time.

Tony

I should've stated rather than implied that Foreskin Man #2 is anti-Semitic. But I think the understanding is sufficiently clear. And in an e-mail I sent to alert someone I knew would be equally furious, I wrote this on December 2, 2010:

I don't know if you've seen it yet, but the 2nd issue is appallingly vile and anti-Semitic. ...

I can't control who creates anti-Semitic filth in a mistaken push against non-therapeutic child circumcision. I can somewhat influence who promotes it after it's been created, but that's limited where there is no organizational structure among independent activists. What I can do is expect to be treated fairly based on my own words and actions. If you're inclined to disagree with me, do so fairly on the principled arguments involved, not because some other guy created something disgusting to ostensibly support the same goal.

June 03, 2011

Opposition to Circumcision and Anti-Semitism

Ken at Popehat has a post today on the proposal in San Francisco to prohibit non-therapeutic male child circumcision. Specifically, he addresses propaganda materials created by individuals associated with MGM Bill, including its founder, Matthew Hess. The charge is that these materials, including a comic book series and trading cards, are anti-Semitic. I'd like to challenge what Ken wrote about it. I can't, though, because I agree that the materials are anti-Semitic and despicable.

I, and others, have worked behind the scenes to counter this sort of nonsense whenever it's popped up, including the original release of these materials from Mr. Hess. This will unavoidably appear, since infant circumcision involves religion and not everyone involved in a movement will have the sense to reject the wrong, unethical approach. As I've read in a few smart places recently, any movement like this will have its anti-religion fringe, but that should not tar the entire movement. There is a principled approach against circumcision that is easily stated and powerful in a way that anti-Semitism can never be. The words of the proposal are straight-forward. As Ken wrote, "there are many arguments to be made against circumcision that do not depend on denigration of religion." We should make them, and only them. Those who do shouldn't be tainted by those who don't.

So, yes, I've encountered anti-Semitism. I do not stand for it when I encounter it, although the only evidence is what I've written here. Being a loosely organized movement, at best, chastisement is the only way to counter disagreement on the means of achieving the necessary goal. I prefer to challenge it behind the scenes where possible to educate rather than embarrass. Unfortunately, this example won't go away, despite behind-the-scenes efforts. And now it threatens to undo any progress principled activists have made. I am furious and powerless, a frustrating combination.

My only hope is that people will not heed this one sentence from Ken, my only objection to his post. He writes: "I hope that it comes to represent the anti-circumcision campaign in San Francisco." It may. It probably will. But it shouldn't. There is already too little thinking involved in most decisions to circumcise. We shouldn't encourage less.

May 30, 2011

Bob Barr Is Anti-Liberty

I voted for Bob Barr as the Libertarian (rather than libertarian) candidate in 2008. My vote was symbolic, since I couldn't support either major party candidate. I knew it was a "waste" then, since it wouldn't amount to anything. I didn't know I was the idiot. Today, I am ashamed of that vote.

From Barr's blog at the Atlanta Journal-Constitution, here's his post on the San Francisco ballot initiative that would prohibit non-therapeutic genital cutting on male minors in the city:

San Francisco, a city that has long been a safe-haven for the liberal elite, ...

At least he declares upfront that he wishes to engage in ad hominem rather than logical debate.

... has been on a ban-happy kick of late. But the City by the Bay may have gone a bridge too far with its latest proposed ban . . . on circumcisions!

Don't think, be OUTRAGED!

After a silly bit about the Happy Meal ban, because banning a food product is somehow no more appalling than banning an unnecessary surgical procedure forced on children, he picks up his mockery:

Now the city may be moving toward an agenda of “genital justice.”

Regardless of whether the city’s Grand Pooh Bahs can defend with a straight face the proposed ban on clipping a baby boy’s foreskin, San Franciscans do appear to be serious about the matter.

San Francisco's "Grand Pooh Bahs" had nothing to do with this, as his next paragraph demonstrates. It was a ballot initiative led by a private citizen. If it had been proposed to the city council, it would've been tossed in the trash can with the same unthinking concern Barr shows here.

The Associated Press reports that local activists have gathered enough valid signatures to place an anti-circumcision referendum on the November ballot. What these activists call “genital mutilation,” would be banned for male children, absent meeting the almost-impossible, “medical necessity” exemption provided for in the referendum. There is no religious exemption. Anyone violating the ban would be charged with a “misdemeanor offense punishable by a fine of up to $1,000 or up to one year in jail.”

The fact that the exemption is "almost-impossible" to meet demonstrates why Barr is wrong on this. It is permanent, body-altering surgery on a healthy person who can't consent to the modification's harms or risks involved. California law already prohibits non-therapeutic genital cutting on female minors. What do the Grand Pooh Bahs of California think of that? What does Bob Barr think of that? Is that "genital mutilation," or is it genital mutilation? Can only female genitals be "cut up or alter[ed] radically so as to make imperfect"? Barr offers no explanation for why male circumcision is Teh Awesome, just that those liberal elites - center square on the Conservative Bullshit Argument Bingo board - support it. Obviously Barr called every one of those who signed the petition to confirm that they're liberals and couldn't possibly argue from any defensible or logical position against non-therapeutic male child circumcision.

Barr concludes:

San Francisco clearly has jumped the shark with this proposal. Even some residents who normally would likely shrug off extreme left-wing campaigns mounted by various activist groups, probably are wondering if things are going a bit too far with this one. They are right to question this proposal. It is about as far off the “Bizarro Scale” as you can get; at least, that is, until we see what San Franciscans come up with next year.

That's it. He doesn't include a single word about why parents should be able to continue forcing genital cutting on their healthy sons. There is no argument here. This so-called libertarian doesn't even attempt the flawed argument in favor of parental "liberty". The only conclusion is that Bob Barr is not motivated by liberty.

Update: I've rethought the title to this post. It was originally "Bob Barr is Unethical and Anti-Liberty." His mockery within his blog post demonstrates that he does not understand, but it's something different to state that he is unethical. Hence, my revision.

February 27, 2011

Dr. Amy Tuteur Is Wrong About The First Amendment (And Still Wrong About Circumcision)

Dr. Amy Tutuer is at it again. She insists on defending circumcision from any rational challenge, and also insists on name-calling. Consider:

The foreskin fetishists have struck again. Those who devote their lives to the preservation of foreskins are hurriedly gathering signatures to put a circumcision ban on San Francisco's November ballot. The measure would assess fines as high as $1,000 and provide for up to one year in jail for someone who performs a circumcision.

Foreskin fetishists is a term used by someone who has no arguments beyond ad hominem. This isn't her first time deploying it. But if that's all it takes to "discredit" an argument, what about this rewrite?

The labia fetishists have struck again. Those who devote their lives to the preservation of labia are hurriedly gathering signatures to put a female genital cutting ban on San Francisco's November ballot. ...

Works just as well, right? Demonize where there is a rational argument to be made against surgical intervention on the healthy genitals of children, and no one needs to think beyond the past. Move on, nothing to see here. It's stupid and rather pathetic, especially since she refers to herself as "The Skeptical OB."

The news article she excerpts refers to the current ballot initiative in San Francisco to criminalize circumcisions on healthy, non-consenting male minors. It states:

“We say: ‘Would you like to help protect the children from forced circumcision? This is a human-rights issue,’” [Lloyd] Schofield said.

To which she replies:

Actually, it's a First Amendment issue, and a ban on circumcision is unconstitutional, because it violates the right to free expression of religion. Circumcision is an integral aspect of Jewish religious practice and is important in the practice of Islam. Of course the foreskin fetishists are not concerned with anything as piddling religious belief.

A ban on circumcision would not violate the First Amendment because it's an individual right. Male minors possess this same right, even in the face of the obvious point that parents may make religious choices for their minor children.

But I'll momentarily concede that the parents' First Amendment right trumps the child's forever. That right doesn't trump the child's right to be free from harm, a fundamental natural right. The courts have already ruled that parents do not possess a plenary right to harm their children in the practice of their religion. The disconnect here is solely that our society does not yet acknowledge the obvious point that circumcision, as surgery, is harm. For example, Tuteur writes in the comments:

Every effort is made to minimize any possible risks and religious circumcision cannot and should not be performed if there is any question that it will harm the infant.

Circumcision removes healthy tissue and nerve endings. It causes scarring. It includes a non-zero risk of complications, ranging from mild to severe, including rare cases of death. It alters the functioning of the penis by removing the gliding and protective features of the foreskin. It is not simply a disposable body part. Contrary to what she stated in the past and clearly still believes, the legitimacy of proxy consent in some cases does not prove that it is legitimate in all cases. The distinction that she misses, which is frightening given that she is an OB, is need. Without medical need, proxy consent is invalid.

But smears are easier than thinking.

January 30, 2011

Barbara Kay Is Mistaken on Circumcision.

I've read many bizarre, irrational rants advocating for non-therapeutic child circumcision. This recent opinion piece by Barbara Kay in Canada's National Post is the worst drivel of that sort I've encountered. (It's a response to a counter opinion piece by Jackson Doughart.)

She begins:

In 1970, some 97% of American males, and about 70% of Canadian males were circumcised. Those numbers have fallen dramatically, thanks in large part to ardent activism by anti-circumcision “rights” groups.

Jackson Doughart believes that the Canadian government should pass legislation that would prevent religious leaders and health-care legislators from performing or authorizing the ritual circumcisions of newborn children. He bases his argument on two often-adduced moral grounds: that the circumcision of infants violates their human rights, because they cannot give informed consent to the procedure, and that male circumcision is a “mutilation,” comparable to female genital mutilation (FGM), already outlawed.

Non-therapeutic genital cutting on a non-consenting individual is morally and ethically wrong. It violates the individual's human rights (e.g. right to be free from harm), regardless of the individual's gender or the subjective reasons provided for the surgery. It would be no less ethical to cut off healthy, functioning fingers or ear lobes than to cut off a healthy, functioning foreskin.

To her second point, there are forms of FGM that are less invasive than male circumcision and performed for many of the same non-therapeutic reasons. Yet, these forms of FGM are still illegal. We recognize that they violate the child's rights because they cause unnecessary harm.

Before addressing Mr. Doughart’s moral concerns, I stipulate to set aside any religious argument for our debate. I can assure Mr. Doughart that Jews, myself included, would unequivocally renounce the ritual of male circumcision if scientists provide a causal link between circumcision and increased risk for morbidity. But after 5,000 years of what is essentially a massive controlled study of Jewish and Muslim men, from which no negative effects can be ascribed to male circumcision, that is unlikely to happen.

She establishes a ridiculous straw man in an attempt to demonstrate that, religious argument aside, child circumcision is moral. It's unfortunately all too easy to prove that circumcision increases the risk for morbidity, but that's not the proper argument. There's far more to the ethical question than her implication that it's obviously good and unassailable if it doesn't kill the patient. And the 5,000 year "controlled study" of Jewish and Muslim "men" really involves children who become men. There's an important difference there beyond the obvious issue of consent since circumcision of an infant is subtly different from circumcision of an adult.

Carrying the straw man to its illogical conclusion, she writes:

Conversely, Mr. Doughart should stipulate to endorse male circumcision if it can be shown to decrease the risk for morbidity. Which it can.

She's ignored the ethical argument of rights, apparently because putting quotes around a word proves it doesn't apply. Somehow. But she's also dismissed the concept of ethics. To her, any intervention is ethical if it decreases the risk of morbidity. In her misguided view, it doesn't matter if the person wants it or is ever likely to need that intervention. If it can decrease some risk, it's automatically ethical.

That's ridiculous, of course. Should we begin studying female genital cutting to determine whether or not it reduces some risk, no matter how small the absolute risk is? What about removal of breast buds from infants? If SCIENCE! trumps any ethical concern, as Kay expects the reader to accept, then there is no intervention on children that can be considered irrational or offensive if it reduces the risk of morbidity in some way. To Kay, science and the application of science (i.e. medical ethics) are the same. They are not the same.

The World Health Organization (WHO) recommends male circumcision on the basis of irrefutable evidence that it dramatically lowers the rate of HIV, not just in men, but in women and children (according to one British researcher, “The foreskin of the penis is a magnet for HIV.”)

With the availability of Google, it's not difficult to learn what WHO recommends. Its recommendation isn't what Kay states it is:

... WHO/UNAIDS recommendations emphasize that male circumcision should be considered an efficacious intervention for HIV prevention in countries and regions with heterosexual epidemics, high HIV and low male circumcision prevalence. ...

That statement does not describe the United States or Canada. Ignoring that - to the point of calling the finding a "miracle" in the next paragraph - is egregious. I'd be curious to understand why she and her editor made this inexcusable mistake, but regardless of the reason, she's wrong. Its actions show that it ignores ethics, like Kay, but WHO does not recommend male circumcision, full stop.

Yet Mr. Doughart shrugs off this miracle, claiming there are “far better ways” to eliminate HIV, like “educating youth about sexual health and condom use.” Actually, both have been tried. They don’t work in significant numbers (although sexual-fidelity campaigns have been effective: is Mr. Doughart on board for those?).

There are (at least) two problems with this. First, the studies in Africa were not long-term. We do not know if the percentage of HIV infections among circumcised males will eventually match the percentage among intact males. There are portions of Africa where circumcised males have higher HIV infection rates. It's reasonable to suggest that males engaging in unprotected sex with HIV-positive women over a long-enough period will become HIV-positive, that circumcision can't prevent HIV. Or they could wear condoms...

Second, the ethical problems with non-therapeutic circumcision of non-consenting individuals isn't resolved by studies on groups of people. The individual is an individual, with his own preferences and possible actions. "Most" males may not use condoms, but any male might. The preferences of an individual who never engages in risky sexual behavior should not be ignored because some number of his peers engage in risky sexual behavior.

Passing to the moral realm, the argument of “informed consent” is easily demolished by the fact that we routinely vaccinate our children against disease without their consent for their own good. Even before we knew of the HIV connection, amongst those circumcising their sons, health and hygiene were always the reason. STDs are much more common in uncircumcised men, and circumcision causes a 12-fold reduction in the incidence of urinary tract infections. Complications from circumcisions performed by experienced surgeons and mohels are as rare as those springing from dental procedures or vaccinations: that’s to say, statistically negligible.

Vaccinations are a red herring. They protect against diseases by activating the body's natural immune response. Circumcision amputates healthy skin on the theory that it might cause problems. (Worth noting: The link between circumcision and reduced risk of female-to-male HIV transmission is not fully understood.) This comparison ignores the likelihood of problems or the means by which the individual becomes sick. An individual can get measles by doing nothing more than venturing into his community. Becoming HIV-positive requires a bit more active behavior, and specifically with one's penis. Preventing such infections is easy, and the method is known. Proxy consent for circumcision can't be sufficiently compared to proxy consent for vaccinations.

As for the rest, earlier in her essay, Kay said there were no negative effects from circumcision. Now she's acknowledging that there are, in fact, complications. That's relevant to her mistaken belief that only increased morbidity matters. She should also prove that such complications are "statistically negligible." (Are they negligible to the males who receive those circumcision complications?)

Kay is also engaging in the common tactic of presenting relative risk rather than absolute risk. For UTIs, the relative risk is impressive in the absence of critical thinking. She neglects to mention that this benefit only exists for the first year of life. The absolute risk of a UTI, however, is not as impressive. It's only 1% for intact males, which is less than the 3% risk of UTIs for females in the first year of life. For the majority of those in the 1%, treatments less invasive than circumcision will be sufficient to resolve the infection.

On to the pernicious myth that male circumcision, a 30-second procedure, is a “mutilation” and the obscene canard that it is the equivalent of sexist FGM. FGM is a horribly protracted and painful cutting of girls under terrifying circumstances, with the specific intention of eliminating the capacity for sexual pleasure, and rightly considered a criminal action. According to UNICEF, at least 100 million women have been genitally mutilated. Compared to their uncut peers, these women are 69% more likely to hemorrhage after childbirth, and up to 55% more likely to deliver a dead or mortally ill baby. For every 100 deliveries, the WHO estimates FGM kills one or two more children.

Not all FGM is "sexist" in the way Kay implies, since it's perpetuated and carried out by women. Nor is all FGM performed with the "specific intention of eliminating the capacity for sexual pleasure." This is the most common result, but we don't look at intent when criminalizing this in the Western world. The federal anti-FGM act in the United States explicitly excludes any parental intent. The act is separate from why it's performed. Parents who cite reasons similar to what society permits for male circumcision are given no more credence than those who intend to inflict the vilest outcomes. The act itself, rather than intent, is the sole criteria. The same must be true for boys.

“Mutilation” is a disgusting word to apply to the excision of a non-essential bacteria trap, nearly painless and instantly forgotten (those who claim otherwise are fantasizing; no credible study demonstrates lasting effects). Unlike ordinary circumcised men, FGM victims know they have been mutilated in the real sense of the word. Feminists constantly remind us that men have all the power. If true, how is it that after so many thousands of years — coincidentally up to the advent of the sexual revolution and the privileging of erotic freedom over ethical mating — so many millions of intelligent and even powerful Jewish and Muslim males never spoke up about their alleged victimhood?

Non-therapeutic genital cutting on a non-consenting individual is mutilation. Among the definitions of mutilate is this: To make imperfect by excising or altering parts. Kay just described circumcision as excision. She is wrong to maintain this disconnect between her accurate word and her inaccurate understanding.

Beyond that, calling the foreskin non-essential ignores the individual. It's absurd. Anything that doesn't kill the individual can be considered non-essential. The term has no relevance to proxy consent for non-therapeutic genital cutting. A male may value and prefer what she considers non-essential on his body. Her belief that the opinion of a male's parents' matters with regard to what is non-essential on his body is wrong. Each person is the arbiter for himself. As long as the individual is healthy, removing any normal body parts is unethical.

Calling the foreskin a "bacteria trap" is no more accurate than calling the vagina a bacteria trap. Bathing is quite easy in our society. Surgically excising a child's foreskin is an abdication of parental responsibility, not a prudent response.

The ability to make a procedure painless does not render it ethical. The ability to "forget" the surgery assumes that the child's experience during the procedure and healing are irrelevant. That is a monstrous view. And the implicit "you can't miss what you never had" argument is equally ridiculous. Circumcision removes the male's foreskin, not his brain. The male is capable of knowing that he has been mutilated, even in the typical scenario where his mutilation is less severe than a female victim's.

The obvious reason why so many men, including but not limited to Jewish and Muslim males, never speak up is because they were circumcised as children. They incorrectly perceive circumcision as normal, rather than common. And, from my discussions with other men, there is a very strong defense mechanism against seeing themselves as harmed. (This same response can be seen among victims of female genital cutting, some of whom don't view themselves as victims.) Our world is more complicated than this imaginary world Kay conjured up.

The responses of these millions of men is irrelevant to the ethical question involving individuals. Kay ignores this. What the individual prefers for himself is what matters for non-therapeutic surgery. If he does not want non-therapeutic genital cutting, he is correct for himself. The rights Kay incorrectly dismisses belong to the individual, not to the majority opinion within his society. If any right belongs to the majority, it is meaningless. Stating that most males don't care about being circumcised is not a defense for forcing it on any individual male.

On the point about "erotic freedom over ethical mating", it's a strange non-sequitur that ties into her last paragraph. So far, she's propped up her indefensible argument with ignorance, straw men, and selective fact-checking. She ends with ad hominem:

Set aside the rights-based rhetoric. It’s about sex: Circumcised men have greater pre-orgasmic endurance; non-circumcision permits more frequent ejaculations. What matters most to the anti-circumcision activists is their diminished pleasure with frequently changing sexual partners, as befits an era where the number of conquests is a more common metric of romantic success than long-term relationships. Our legislators have better things to worry about than this.

On par with calling the foreskin a "bacteria trap", stating that circumcision imparts "greater pre-orgasmic endurance" is propaganda. She is saying that circumcised males take longer to reach orgasm, which she expects us to grasp as "good". She's making a value judgment that endurance is objectively better. It isn't because she's unavoidably declares that sex is changed by circumcision. Again, all individual tastes and preferences are subjective. Some males will value "pre-orgasmic endurance." Some will not. Each is right for himself, so imposing it on all is unethical.

Instead of attempting to prove that the subjective is objective, she states that males against non-therapeutic child circumcision merely want to have lots of promiscuous sex with as many people as possible. She presented no evidence to suggest what activists prefer or what circumcised males would do if left intact. Her smear attempt is embarrassingly stupid.

However, it's worth exploring the implicit sentiment in her ad hominem attack. "Ethical mating" is supposed to be better than "erotic freedom" in some objective, provable manner to Kay. Since circumcision allegedly promotes "ethical mating", circumcision is allegedly good. But what she's saying is that circumcision can and should be used by parents as a tool to control male sexuality. She rightly denounced sexism that attempts to excuse female genital mutilation, so why does she endorse sexism to excuse male genital mutilation?

August 18, 2010

Hanna Rosin Is Still Mistaken on Circumcision. Uh Oh.

Yesterday, the New York Times ran an article about a recent study (on a semi-related topic) that suggests the U.S. infant male circumcision rate fell to 32.5% for 2009. This has been floating around for a few weeks. Frankly, I don't believe it, as much as I'd like it to be true. When the data are fully analyzed, we'll either see the rate climb or the exclusions will reveal circumcisions that weren't counted but must logically be assumed (e.g. ritual). I'm aware of my culture's insanity.

This story has, predictably, brought out the usual folks and their BUT TEH AIDS!!!!1 rhetoric. For example, a year after showing her ignorance and bias¹ for circumcision, Hanna Rosin returns to prove that she's still willfully ignorant.

The New York Times reports today on new findings that circumcision rates have declined precipitously in the United States, from 56 percent in 2006 to 32.5 percent last year. That’s a phenomenal decline in just three years. ...

No kidding. It's so phenomenal that, were she ever willing to break out her critical thinking skills, she might focus her blog entry on that point. Instead, she regurgitates the same incorrect, irrelevant propaganda.

... The story quotes doctors saying that of course no one in the profession should ever tell a parent to circumcise their child and the Centers for Disease Control declines to comment because they never do on this issue, even though they know full well that the drop in circumcisions is a potentially serious public health problem. ...

That quote is this:

“No one is going to tell a parent, ‘You have to circumcise your child.’ That would be foolish,” Dr. [Michael] Brady said. “The key thing physicians should be doing is providing information on both risks and benefits and allow the parent to make the best decision.”

Any doctor who agrees with that is an unethical coward. The key thing physicians should be doing is rejecting the offensive parental request to surgically alter healthy children boys.

As for what they "know full well," this from the New York Times article:

Some 80 percent of American men are circumcised, one of the highest rates in the developed world. Yet even advocates of circumcision acknowledge that an aggressive circumcision drive in the United States would be unlikely to have a drastic impact on H.I.V. rates here, since the procedure does not seem to protect those at greatest risk, men who have sex with men.

Context matters, a caveat Rosin ignores.

Continuing:

... But circumcision has become like abortion these days, where allying yourself with the Mengele doctors who mutilate infant boys risks bringing a horde protesters to your office door.

Doctors (and non-doctors) who circumcise healthy boys mutilate them:

1 : to cut up or alter radically so as to make imperfect
2 : to cut off or permanently destroy a limb or essential part of

Words have meaning independent of the desired preference of pro- or anti- child circumcision arguments. For mutilation, that meaning is independent of the victim's gender and the proxy's intent.

She continues:

It does not really matter if any individual parent decides that circumcision is not for them, as I explained in this New York magazine story, “The Case Against the Case Against Circumcision.” ...

This is the crux of her mistake. The (unnecessary) circumcision Rosin defends is not for the parent. It's imposed on the individual child boy. This is why it's unethical, regardless of all the unimpressive, incomplete facts she shares. It's not about what the parents want, but what the boy needs. Proxy consent has objective, logical limits. That our society ignores these does not reduce their validity.

Continuing:

... But it absolutely matters if a whole society turns against the practice. The exact relationship between circumcision and the prevention of certain diseases – from AIDS on down – is not perfectly understood. ...

Promote anyway, apparently, since there's no chance missed factors could contribute to the conclusion.

... But it is absolutely understood that societies in which the majority of boys are circumcised have lower rates of such diseases than other societies.

From AVERT, worldwide AIDS & HIV statistics from 2008 show that North America has an adult prevalence of 0.4%. Most 15-49 year old American males are circumcised. Canadian circumcision rates are declining, but a large percentage in that age group are circumcised. Western & Central Europe, where most males are intact, has an adult prevalence of 0.3%. But it is "absolutely understood" that mutilating societies have lower rates of such diseases. Rosin is entitled to her own facts, apparently. She knows.

Still more:

Anti-circumcision activists have convinced us that circumcision is harmful and dangerous and does a lifetime of damage. ...

Circumcision is surgery. It removes healthy tissue and nerves. That's harmful. Every boy suffers some form of harm (e.g. scarring), but some boys suffer far worse. Collectively it is not "dangerous", but individuals are not statistics. And since this damage is permanent, it certainly lasts a lifetime.

If a male chooses circumcision for himself, that is his right, regardless of his reason. The issue is its imposition on healthy, non-consenting children boys. Their health proves how the science involved is twisted, since only potential benefits seem to count as "science". Their lack of consent proves the ethical argument against permitting prophylactic circumcision (i.e. ritual, cultural, and "scientific"), unless Rosin wishes to open proxy consent to medically unnecessary genital surgery on female minors.

¹ I also highlighted her ignorance and bias here and here.

May 10, 2010

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.

May 07, 2010

A Request

Seeing how the AAP's revised policy statement on female genital cutting is inducing mass outrage, I think I need to revisit the issue. My initial analysis is very different from the basic, solidifying narrative. I'd planned to follow-up during lunch today, but there's too much information to adequately address in this short time. I'm going to clarify my thoughts over the next day or so.

My request: I know people read what I write here about circumcision. If you read my blog entry on the AAP's policy statement, let me know if you think there are any flaws in what I wrote, or if there are areas that I wasn't clear. I want to make sure I get this right, but I'm perplexed that my take is so much different than what's being said elsewhere. I don't think I've misread the policy statement, but I want you to tell me I'm wrong if you think I have. Thanks.

May 04, 2010

A Universal Standard of Basic Human Rights Isn't Divided By Gender Or Culture

UPDATE:I corrected a word from the original entry to clarify my intent. I understand that the AAP is not a government organization. I've corrected the poor wording.

The American Academy of Pediatrics' Committee on Bioethics issued a new policy statement on female genital cutting, titled "Ritual Genital Cutting of Female Minors". It updates the organization's previous stance. Mostly it's predictable statements against all female genital cutting (FGC), which won't be controversial in the United States. But there are a few bits of odd reasoning included.

From the abstract:

... The American Academy of Pediatrics opposes all types of female genital cutting that pose risks of physical or psychological harm, counsels its members not to perform such procedures, recommends that its members actively seek to dissuade families from carrying out harmful forms of FGC, and urges its members to provide patients and their parents with compassionate education about the harms of FGC while remaining sensitive to the cultural and religious reasons that motivate parents to seek this procedure for their daughters.

This is unobjectionable without focused reading. But it explains what is coming in the policy statement. Most Americans will read "opposes all types of female genital cutting that pose risks of physical or psychological harm" to mean no cutting should be permitted on healthy girls. The policy statement doesn't refute that because, as it acknowledges, all non-therapeutic genital cutting on female minors is prohibited in the United States. In the body of the statement, this:

Protection of the physical and mental health of girls should be the overriding concern of the health care community. Although physicians should understand that most parents who request FGC do so out of good motives, physicians must decline to perform procedures that cause unnecessary pain or that pose dangers to their patients' well-being.

Reading what isn't being said demonstrates that the committee fails to endorse complete opposition to FGC, either. For example:

... Most forms of FGC are decidedly harmful, and pediatricians should decline to perform them, even in the absence of any legal constraints. 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.

I think there's merit to this argument. It fits the details of proposed accommodations at Harborview Hospital in the '90s for Somalian immigrants. From a practical standpoint, a ceremonial nick to draw a drop of blood is better than an excision. Discussion without invectives would be helpful.

However, I don't want to imply that I endorse this strategy. I reject it as a matter of law and practice because children possess the same basic, natural human rights as adults. (There's no distinction for the gender of the child, which I'll address shortly.) Legislating such an exception, or refusing to prosecute such violations of existing law, legitimizes ritual and cultural genital alteration. It moves the discussion from should it be allowed to how much should be allowed. It dismisses the child, the individual whose genitals face the scalpel.

Related to that, the statement includes this:

There is also some evidence (eg, in Scandinavia) that a criminalization of the practice, with the attendant risk of losing custody of one's children, is one of the factors that led to abandonment of this tradition among Somali immigrants.

There are options and paths to pursue before we embrace moral relativism.

Predictably, the statement avoids acknowledging American hypocrisy on the topic of male genital cutting. This is particularly worth noting as some seek to move the AAP's (and assorted governmental bodies) official stance on non-therapeutic male child circumcision from its relative neutrality to deliberate advocacy. In the introduction of its updated FGC policy, it states:

The language to describe this spectrum of procedures is controversial. Some commentators prefer "female circumcision," but others object that this term trivializes the procedure, falsely confers on it the respectability afforded to male circumcision in the West, or implies a medical context. ...

Any fair, honest treatment of its words would recognize that male minors have the same rights. That excerpt should be rewritten to state that referring to female genital cutting as circumcision "confers on it the false respectability afforded to male genital cutting in the West".

This follows the last excerpt:

... The commonly used "female genital mutilation" is also problematic. Some forms of FGC are less extensive than the newborn male circumcision commonly performed in the West. ...

This is from the same organization that "opposes all types of female genital cutting that pose risks of physical or psychological harm." The newborn male circumcision commonly performed in the West imposes objective physical harm in every case, yet the AAP refuses to reject it, preferring platitudes about parental choice. From the abstract of its policy statement on male child circumcision:

Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. If a decision for circumcision is made, procedural analgesia should be provided.

According to the AAP, parents may impose physical harm on their sons, violating the "principle of nonmaleficence" cited as a reason to reject FGC. Yet, in its revised FGC policy statement, the committee writes:

Parents are often unaware of the harmful physical consequences of the custom, because the complications of FGC are attributed to other causes and are rarely discussed outside of the family.

Changing "FGC" to "MGC" in that statement makes it no less accurate. Briefly perusing almost any news article or essay discussing male circumcision will reveal this.

Near its conclusion the committee writes:

The American Academy of Pediatrics policy statement on newborn male circumcision expresses respect for parental decision-making and acknowledges the legitimacy of including cultural, religious, and ethnic traditions when making the choice of whether to surgically alter a male infant's genitals. Of course, parental decision-making is not without limits, and pediatricians must always resist decisions that are likely to cause harm to children. ...

Including cultural, religious, and ethnic traditions when making the choice of whether to surgically alter a male infant's genitals is not legitimate. It is unethical, immoral and offensive to anyone who alleges to respect universal principles against causing harm. The committee's second sentence shows its hypocrisy. It tells pediatricians to respect and aid parents who (ignorantly but unintentionally) wish to harm their sons. It's moral relativism instead of clear principles respecting individuals. It's unworthy of a civilized society.

Contrary to my initial concern, the revised policy statement does not explicitly advocate acceptance of lesser forms (i.e. Type IV) of female genital cutting. But it hints that it's willing to look the other way if anyone wants to substitute Type IV for a type that won't be practiced in the United States. Discussing such substitutions is a reasonable approach, but the committee cowardly avoids taking a stance, choosing to introduce the topic while letting others draw conclusions. It attempts to straddle both sides of the FGC debate to let each side read into its statement what it wants, if they're unwilling to question or acknowledge anything that contradicts their preferred, limited viewpoint. Anti-FGC advocates are (correctly) upset, but the appeal of this approach is to those who believe that a potential benefit is science but the objective current health of a child is not. The AAP can plausibly say it opposes all female genital cutting, while also plausibly saying it recognizes the complexity of FGC as it's practiced and is sensitive to the people who practice it on their children.

April 15, 2010

Education Without Understanding

Here's a story about a male who decides to have himself circumcised:

"It was a thing I had wanted to do for so long - I work in the health sector so I'd been reading books, discovering the importance of one getting circumcised, that's why I decided to come.

"Mostly I was interested in the healthier status – the better hygiene, the partial prevention of HIV [in men] and the [possible] lesser chance of infecting your partner [with the human papillomavirus, linked to cervical cancer].

"I talked to my fiancée to say I wanted to get circumcised, because sometimes ladies say, 'Why?' I ... [explained] why I wanted to go for circumcision and she accepted it.

"I talked to her about [having to wait six weeks for the wound to heal before having sex]. It's a thing that we needed to discuss, when it comes to that, so that she should not get surprised as to why this thing is not happening - she was expecting to wait.

"It wasn't difficult to talk to her but, again, this is a girl that I would like to marry. [Also,] we are not in that situation where we are staying together; she stays at her parents' and I stay at my house ... maybe with married couples sometimes it may be difficult.

This is where rote memorization of the biased propaganda surrounding non-therapeutic circumcision is a dangerous problem. This man is engaged, so he's presumably monogamous with his fiancée. What benefit will he receive from the potential for circumcision to reduce the risk of HIV or HPV transmission? If he and his fiancée are currently free of both, circumcision will have no benefit unless one of them has sex with another individual, one who is infected with HIV and/or HPV. Effectively, he's surrendered to hysteria. (And his story is being used to sell circumcision on the same grounds.) I don't wish to imply that this is what advocates of non-therapeutic circumcision want, but it's the predictable, unacceptable result when relevant facts and context are ignored (or rejected).

Post Script: Given this man's stated reasons, hygiene is still on the table. In a world with access to running water, this isn't a concern unless he doesn't bathe regularly. I assume he does, but if not, then the issue is not with his foreskin.

March 30, 2010

Just a reminder...

As always, when public health officials talk about voluntary, adult male circumcision, they never mean voluntary or adult.

THE Ministry of Health is targeting to have over 100 000 men circumcised in three years time, Minister Benedict Xaba told senators at the weekend.

Presently, only 4 370 men have been circumcised. “The policy and strategy for male circumcision have been passed by cabinet. Together with partners such as FLAS (Family Life Association of Swaziland) and PSI (Population Services International), we are scaling up the programme so that even infants – 30 000 are targeted- would be circumcised. [emphasis added]

It's easy to meet a numerical target when the recipients can't opt-out of your scheme. This makes me angry, of course. But it gets better:

“Mobilisation in communities has already been done such that chiefs are now sensitised about it. This programme is well funded by PEPFAR.”

My government, instituted to protect natural human rights, didn't protect mine when I was born and now it takes my money and uses it to fund others who will violate those same natural rights of children born today.

March 11, 2010

Grace, go to bed. You obviously have had a very busy day of crazy.¹

Here's actress Debra Messing testifying before the House Foreign Affairs Subcommittee on Africa and Global Health in her role as an ambassador for PSI, asking for more federal tax dollars to support "voluntary, adult" male circumcision in Africa (emphasis added):

... I would like to tell you today about two prevention tools that could make a difference if there is continued investment: male circumcision and HIV testing and counseling.

First, voluntary adult male circumcision. There is now strong evidence that male circumcision reduces the risk of heterosexually acquired HIV infection in men by about 60 percent, yet only about one in ten Zimbabwean adult men are circumcised. PSI and its partners run circumcision clinics in Zimbabwe and other countries, with support from PEPFAR and other donors.

I was invited to observe the procedure, which is free to the client, completely voluntary and according to the young man I spoke with who underwent the procedure, painless. The cost of the procedure at that clinic—including follow-up care and counseling—is about $40 U.S. dollars.

UNAIDS and the World Health Organization have issued guidance stating that male circumcision should be recognized as an important intervention to reduce the risk of heterosexually acquired HIV infection in men.

Even with no demand creation, the clinic I visited serves upwards of 35 clients per day. It is estimated that if male circumcision is scaled up to reach 80 percent of adult and newborn males in Zimbabwe by 2015, it could avert almost 750,000 adult HIV infections—that equals 40 percent of all new HIV infections that would have occurred otherwise without the intervention—and it could yield total net savings of $3.8 billion U.S. dollars between 2009 and 2025. Male circumcision programs get robust support from the U.S. government in Zimbabwe and other countries, but greater resources would yield greater results.

Always remember that when public health officials - or actresses - talk about voluntary, adult male circumcision, they never mean voluntary or adult.

¹ Title quote reference here.

February 16, 2010

Massachusetts Will Debate The Right to Bodily Integrity

The Massachusetts legislature is considering a bill that would make non-therapeutic genital cutting (i.e. circumcision) on healthy minors illegal.

...

(a) For the purpose of this section, the term “genital mutilation” shall mean the removal or cutting or both of the whole or part of the clitoris, labia minora, labia majora, vulva, breast, nipple, foreskin, glans, testicle, penis, ambiguous genitalia, hermaphroditic genitalia, or any genital organ.
...

Reading the bill in its entirety shows that the author(s) shaped it directly from the Federal Prohibition of Female Genital Mutilation Act, while correctly updating the text to remove the federal law's gender discrimination. It includes protection for females, which is useful (if likely redundant) since Massachusetts does not have a state law prohibiting female genital mutilation. The Massachusetts bill is reasonable and should move out of committee, where it's scheduled for a public hearing on March 2nd, and pass into law.

It won't, of course. I'm hopeful it will at least get an honest hearing, but I've worked on this topic too long to be that naive. Too many people are unwilling to consider all facts, particularly those detrimental to their status quo preferences.

For example, this editorial from Massachusetts, from Wicked Local, reveals that its authors fail to understand even the actual text of the bill.

Thumbs Down:

Circumcision is a crime? Through state Sen. Michael W. Morrissey, Charles Antonelli of Quincy has decided to waste the Senate’s time with a bill that would ban male circumcision of anyone under the age of 18 in Massachusetts unless medically necessary. The measure would get right in the way of parental rights, imposing a fine and/or up to 14 years in prison on people who violate this ban. Antonelli is the Massachusetts director of MGMbill.org — a group of “we know better than the majority of doctors” nuts working to ban what it calls “male genital mutilation.”

Is it a waste of time to get in the way of parental rights to alter a daughter's genitals? Because the bill does that, as the excerpt above proves. The federal Anti-FGM act does the same. So, the question here is what is the full list of plenary parental 'rights' that require only that the child have a penis?

For what it's worth, if a doctor believe a healthy child needs surgery, yes, I'm more informed than he or she is. And he or she violates the Hippocratic Oath when recommending genital cutting, regardless of the healthy patient's gender.

This group shoves aside the belief held by most of the medical community that circumcision reduces susceptibility to HIV and other sexually transmitted diseases as well as urinary tract infections and penile cancer. The anti-circumcision group declares “those findings are not a valid reason to amputate a healthy, functioning body part of a child.”

I won't speak for those involved with MGMBill.org, but for me, I shove nothing aside. Prophylactic circumcision has the potential to achieve those results, statistically. So what? Because, somehow, possessing an objectively healthy, functioning body part does not indicate that surgery is not valid for that healthy, functioning body part. There are apparently no ethical considerations involved. There is apparently no need for an objective look at the relative and absolute risks involved. There is apparently no need to question whether or not the child might want his normal, healthy foreskin.

It's frustrating that Wicked Local defiantly states that circumcision reduces susceptibility to HIV without also noting that every study showing this risk reduction involved only adult volunteers, not non-consenting children. Note, too, that the studies only found a reduction in female-to-male transmission through vaginal intercourse, a significantly smaller problem in the United States than in Africa.

But Wicked Local seems to perceive the issue to be about only potential benefits, no matter how trivial or easily avoided with lesser methods the risks posed by the foreskin. So surely we are failing all children by not proactively removing dangerous body parts from their bodies. To avoid getting in the way of parental 'rights', when do we start studies to determine whether or not there is a potential medical benefit to be achieved from prophylactic breast tissue removal? Although, since some adult women are already voluntarily having their breasts removed pre-emptively, we can assume that a plenary parental 'right' to remove the healthy, functioning breast tissue from daughters exists. What's good enough for the parents is good enough for the children. Right?

That's all intentionally absurd, of course. But without a boundary, there is nowhere to end the madness. The subjective boundary Wicked Local establishes here is arbitrary and based on its editors personal preferences. The law cannot be based on such whim. For proxy consent, the child's objective needs matter first. Where there is no objective need for intervention, there is no parental 'right' to intervene. Surgery must be prohibited. That is a clear standard that applies to males and females, genitals and not genitals.

Also ignored is Jewish and Muslim tradition in which all males are usually circumcised as part of their faith.

Passive voice, males are circumcised. They do not choose. Indeed. But this bill does not seek to prohibit religious circumcision. Adult males may still choose circumcision for themselves if they believe their God demands it. This bill focuses on minors, where civil law must take precedent over religious texts. It codifies that the human rights of every individual exist first, and no amount of parental preference can supersede that in the pursuit of subjective, unprovable spiritual or cultural benefits. Unless we're opening the law books to strike any law that violates a religious dictate governing what one person may do to another, there is nothing objectionable on this front. Are we opening the law books in this manner for a purge of religiously objectionable civil laws?

The bill has not yet been assigned to committee. It would be best to see this ridiculous waste of government time sniped from the legislative agenda and left discarded on the Senate clerk’s floor. Parents and doctors, not legislators, should decide the merits of whether a male child should or should not have a circumcision.

Parents and doctors, not legislators, should decide the merits of whether a female child should or should not have genital cutting? Again, if we're saying that parents have a plenary 'right' to alter their sons for subjective reasons, the same plenary 'right' must exist for their daughters. Or we could consider the importance of the omitted word, a healthy child, and recognize that the answer is irrefutable because it is illegal (and immoral) to discriminate based on gender alone. Either all children have the same right to bodily integrity or no children have that right. The former breaks our current ignorance, while the latter turns children into property.

And here’s a tip for the angry anti-circumcision group — you would do a lot better with an informative public education campaign and debate rather than going state-to-state trying to shove your will on everyone and toss parents who don’t agree with you into jail for up to 14 years — a tact that so far has not seen even one state go along with this nonsense.

I agree, an informative public education campaign and debate is the best way to go. We shouldn't need to legislate against something unjust. But we do, because the rights of boys in America (and Massachusetts, in this case) are violated every day. I can explain how male circumcision is egregious because it violates human rights. I can explain how male circumcision is egregious because it is not the least invasive solution for every perceived benefit. But the Wicked Local editors haven't even bothered to understand the text of the bill. I can overcome ignorance. I cannot overcome willful ignorance.

November 01, 2009

Science Requires Ethics, Part 3

Jake responded to my last entry in our ongoing series. (My first and second entries.) I'll just jump in. Addressing my view that he is a pro-circumcision advocate, Jake writes:

I find this a rather peculiar statement. I suppose in a sense that any attempt to weigh benefits against risks will have some subjective qualities, and perhaps that can't be avoided altogether. However, as subjective values are meaningless to another person I would hope that most observers try as objective as is reasonably possible. I certainly try; I can only hope that I succeed.

I am uninterested in convincing or encouraging parents to circumcise their sons, and have been careful to avoid making a recommendation either way. Anyone sufficiently interested (not to mention patient) can verify this by working through the many thousands of my public comments over the years - I use the same name everywhere, so it is not difficult to find them via Google. Indeed, I believe that such advocacy would be contrary to my pro-parental choice position: I genuinely believe that parents should make that decision, not me.

Unlike my perception of many individuals I've encountered when discussing circumcision, I believe that Jake advocates parental choice with the intention he states, which is that I think he accepts the decision by parents who do not choose to circumcise their sons. Many parental choice advocates do not believe that decision is valid in their parental choice worldview. In that respect, my saying that Jake "uses his conclusion to encourage parents to circumcise" was incorrect.

Rather, I believe that he is effectively a pro-circumcision advocate because he views his assessment of circumcision as containing some level of objectivity. It can't, just as my assessment can't. The difference between our views, I think, is that mine involves the child's opinion, placing it above that of his parents.

I don't have an opinion on circumcision, per se. I think it's an odd choice for a healthy male to make, but that's the lens of my preferences and experience. Jake has his own opinion, which is clear from his choice to have himself circumcised as an adult. Again, I think that's odd, but my opinion on that is irrelevant because his choice is valid for him.

On the topic before us, though, the focus of infant circumcision must be infant circumcision, not infant circumcision. I write from the former, while I believe Jake writes from the latter. That difference is why I claim that his conclusion is subjective and incomplete.

Next, Jake considers my take on an appeal to authority:

My first inclination was to agree, but on reflection I think it would depend on the situation. Consider the following hypothetical scenario:

PERSON A: Circumcision is awful because the AAP don't recommend it.
AAP: [Introduces a recommendation in favour of circumcision]
PERSON A: Oh, the AAP are biased, ignore them.

Here the appeal to authority is utterly invalid. It is quite apparent that it is a sham: the AAP are being presented as an authority merely because the person hopes to gain an advantage by doing so. The person clearly has no integrity, nor any credibility, and can and should be ignored. ...

This scenario is close to what I considered. Although I wouldn't go as far as Jake does in condemning the person's integrity without more information, it is the response I predict any person to have to the scenario and why I despise appeals to authority.

Even though Jake's first scenario exemplified my point, his second scenario is instructive:

... Now consider this:

PERSON A: Circumcision is awful because the AAP don't recommend it.
AAP: [Introduces a recommendation in favour of circumcision]
PERSON A: Okay, the AAP now recommend it, so it's okay.

In this situation, it seems to me that this is a valid appeal to authority, in that the person is willing to adapt their position once the authority changes theirs.

I disagree, again because the focus of the appeal is infant circumcision, not circumcision. It's an abdication of judgment in favor of someone else's conclusion. If Person A is the individual being circumcised, I am indifferent to his acceptance of the authority's conclusion and judgment. That's not what's at stake.

It's possible to make this too broad. I am not suggesting that expert opinion is worthless or should be ignored. I am saying that, when the focus is on infant circumcision, and specifically the circumcision of healthy infants, citing the authority's subjective conclusion of a net benefit (or neutrality) is a diversion from the individual child's lack of need and possible preference for keeping his normal foreskin. The AAP is relatively neutral today, and I contend they're wrong because they ignore facts (out of philosophical ignorance).

Next, on circumcision versus vaccination:

I see: Tony applies a different standard for surgery and vaccinations. This doesn't make much sense to me, for several reasons. Firstly, from an admittedly pedantic point of view, is there really that much of a difference? Surgery involves risk. Vaccinations involve risk. Surgery involves cutting the skin. Vaccinations (as delivered by a needle) also involve cutting the skin, albeit in a minor way. So I have to ask, where exactly would you draw the line?

Secondly, does it make sense to create multiple standards? To my mind, no. But I may be biased: I'm trained as an engineer, and when I observe lots of different little rules I see a situation in which there ought to be one, more general rule. Special cases are usually an indication that the general rule needs some more attention. Maybe one shouldn't apply engineering principles to ethics. I don't know, but I can't see any reason why one shouldn't...

Yes, there is a difference. Surgery removes a healthy, functioning body part. Vaccination does not. I draw the line between them for that primary reason. So, yes, it makes sense to create multiple standards.

In turn, it doesn't make sense to create multiple standards for boys versus girls for the same parental activity and justifications. Later, in response to my view that anti-FGM laws would not be overturned if female genital cutting was shown to have potential benefits, Jake writes:

In an ideal world, I wish I could say that anti-FGC laws would indeed be overturned if scientific knowledge changed significantly. However, I'm sorry to say that Tony is probably right in that they wouldn't be. I don't think that this has anything to do with rights, though: it's a simple case of collective prejudice. The notion that FGC is horrific is deeply ingrained into modern, Western society, and it takes an awful lot to dislodge that notion. I know this from personal experience: I have to make a conscious effort to think about FGC objectively, and have to fight the knee-jerk reaction. And I consider myself very open-minded.

I accept that circumcision can have potential benefits. I am opposed to prohylactic¹ infant genital cutting because pursuing these potential benefits for an individual who can't consent is unethical. It is unethical because there are real and potential harms. Jake is wrong in his view because he is valuing science in a manner that leaves it insufficiently tethered to ethics. It's a view that, because we can achieve something, it is ethically valid to pursue it. I find that approach abhorrent. It gives parents the choice to pursue an option that is not theirs to pursue. Their opinion must be subordinate to the objective facts of their child's healthy body.

To my point that adults can choose condoms and that parents can't know if their sons will be irresponsible, Jake replies:

To both points, I agree. Nevertheless, it seems difficult to deny that if it were performed during infancy, circumcision would help to reduce this risk when the child became an adult.

I'm not denying that it might help reduce this risk, but it requires a specific, low-risk, low-probability situation to be effective. The choice of surgery to chase a miniscule benefit must be left to the individual.

Of course, it's worth a reminder that the studies in Africa involved adult volunteers. Leaving aside the ethical difference, declaring that circumcision would help males (especially Western males) circumcised as infants is speculation. There are more variables involved, including the foreskin's adherence to the glans in infants and the prevalence of HIV in the society.

In response to my review of his opinion on "most effective/least invasive":

Here I believe Tony has misunderstood, or at least has not considered the issue with sufficient care. If there is a medical problem to address, then the physician's responsibility is to solve that problem while exposing the patient to the least risk. That's the essence of the "most effective/least invasive" standard. But if there is no medical reason for considering circumcision, then it is meaningless to even consider the "most effective" solution. If circumcision is being considered for non-medical reasons then it is in all probability the only solution to the problem (that being that the child is not circumcised). So it is the wrong standard to apply.

I believe I've understood him correctly. He is wrong. If there is no medical reason (i.e. need) for circumcision, it's unacceptable to permit it on children. Normal genitals are not a "problem," no matter how opposed the boy's parents are to his normal genitals. I repeat my earlier criticism: Jake is begging the question he wants to answer. Medical need is the standard for proxy consent to surgery. Without medical need, the process stops. No intervention is valid.

Next:

At this point Tony declined to list '"surgeries we recognize as offensive" that are valid when benefits and risks are properly weighed', stating:

I am not citing any particular science or surgeries because that was not my point.

This is a shame. I had hoped that Tony would at least try. I cannot think of any, and my suspicion is that this is because none exist. And if none exist, then Tony's earlier objection that "Setting the ability to chase potential benefits as the ethical standard opens the range of allegedly valid parental interventions to include any number of surgeries we recognize as offensive" seems a rather empty objection.

Immediately following my objection, I wrote that "I am attacking a way of thinking," which is to say that I reject the notion that because we can achieve a potential benefit, it is ethically valid to pursue it. At its core, prophylactic infant circumcision is about chasing potential benefits. I reject that for the multitude of reasons I've presented. Speculating that I did not cite any because none exist is a straw man.

Citing "surgeries we recognize as offensive" is a pointless diversion. However, I'll play along briefly. I nominate removing the breast buds from infant females to reduce their risk of breast cancer. I have no idea if this would work or it's been studied in any manner. It doesn't matter, because my point was to reject the thinking that believes a potential benefit may be chased. I suspect this would be offensive to most parents, as it almost always is when I raise it in debate. Non-essential, healthy, functioning breasts are different from non-essential, healthy, functioning foreskins, somehow. My guess is that Jake's approach to this would be his utilitarianism, which would assess whether removing breast buds has a potential benefit. (Unless he has some objection I haven't determined.) If it does in his evaluation, it is a valid choice for parents, even if only chosen by those few parents who don't find it offensive. I reject that because the healthy girl may not want the intervention.

Next:

It is meaningful to compare female genital cutting to male genital cutting because, ethically, they involve the same issue. Unnecessary surgery on a non-consenting individual is wrong.

If you take that last sentence as axiomatic, then you will probably see the two issues as similar (although, presumably, there's no reason to focus on genital surgery in particular). Those of us who adopt a different ethical principle - something like "harmful surgery on a non-consenting individual is wrong" see no problem with circumcision, and a problem with female genital cutting.

(I realize that I'm about to object to an issue of semantics in his axiom, but I'm certain I've gotten the gist of any future clarification correct.)

All surgery is harmful, including circumcision. It's meant to achieve some benefit greater than the harm. Jake concludes that circumcision is, at worst, neutral. But that is his subjective evaluation. It is as irrelevant as my opinion that it is a net harm. Proxy consent is not valid for prophylactic infant circumcision because circumcising healthy infants is objective harm pursuing subjective benefits. Jake writes:

... Evaluation of potential benefits should not be dismissed as mere opinion. The literature contains a relatively large amount of data, which can be summarised in the form of objectively quantifiable data.

Potential benefits are based on objectively quantifiable data. Determining the value of applying those objectively quantifiable data to the objectively healthy penis of an infant male is subjective, mere opinion. Deriving an opinion is only valid for the male himself as applied to his body.

Finally:

There is an obvious double standard. Girls may not have their healthy genitals cut for any reason. Boys may have their healthy genitals cut for any reason. That's the valid comparison.

That's not even correct. Try getting a surgeon to perform a glansectomy on a healthy boy. Or castrate him. Or perform any number of other surgeries on his genitals. He or she will refuse. Most such surgeries are a net harm (except when actually needed, in which case the benefits are considerably greater, thus making them a net benefit), and cannot therefore be ethically performed. Circumcision is unusual precisely because it is a surgery which is neutral or (depending who you ask) a net benefit. And that's why the reason for a specific circumcision doesn't really matter.

I think it's obvious that my declarative statement about genital cutting implied "as it's commonly practiced in Western society," which would preclude intentional glansectomy, for example. Moving on.

What Jake omits here is telling. Circumcision is neutral or a net benefit, according to him. He's ruled out that prophylactic infant circumcision can be a net harm, the glaring mistake in his analysis.

A male who suffers a serious complication from circumcision would unquestionably qualify as experiencing a net harm. That risk is inherent in every circumcision. But leaving that aside, a "normal" circumcision has results. Evaluating those results, even if just on a cosmetic level, is a subjective process. There is no correct, objective way to evaluate a change, which is what circumcision is. All tastes and preferences are subjective to the individual. Even a preference regarding the potential health benefits of circumcision. The possibility of "No, thank you" is why infant circumcision is unethical.

¹ I am no less opposed to ritual infant circumcision. Discussing it in depth here would be a distraction. For a primer on my opinion, see here.

October 25, 2009

Science Requires Ethics, Revisited

Jake Waskett responded to my critique of his entry about Intact America's letter. I find it lacking.

... It's a shame that he mischaracterises me as a "pro-circumcision advocate", though (I'm pro-parental choice, not pro-circumcision).

I do not accept that I've mischaracterized his position as a pro-circumcision advocate. However, I'll clarify to be as specific as possible. He believes the potential benefits of infant male circumcision outweigh the risks and negatives, a subjective conclusion based on his preferences. Given that he uses his conclusion to encourage parents to circumcise their sons, the difference he states is immaterial.

Next:

... has attempted a deconstruction of the letter, labeling it "propaganda".

"Labelling" seems a curious choice of word, implying that the choice of term is dubious. Propaganda is defined as "The systematic propagation of a doctrine or cause or of information reflecting the views and interests of those advocating such a doctrine or cause." Thus, it seems a perfectly appropriate choice of term for an advertisement created by an anti-circumcision organisation for the explicit purpose of promoting their cause to the AAP.

This is a matter of semantics versus intention. Definitionally, propaganda is an acceptable choice. It is also impossible to ignore the cultural implication of the use of the word. We do not think marketing when we hear it. Rather, we hear lies. That was the intent I perceived, which informed my response.

Still, it's a minor point in the realm of this topic. Obsessing on it would be a diversion, so I retract the point.

Next, when I wrote that I agreed with the opening paragraph of Intact America's letter, I stated that I'm not a fan of appeals to authority. Specifically:

As should be evident with the apparent intention of the CDC to recommend infant circumcision, it only takes one ill-conceived recommendation to distract from the core issue.

Jake writes that this is "utterly incomprehensible." I'm not sure how, so I'm not sure how to clarify. If an authority cited directly (e.g. AAP) or indirectly (e.g. CDC) changes its position in a way that then conflicts with the original appeal, the appeal to authority may weaken the case for the target audience. It's an ineffective strategy.

Despite my misgivings, Intact America structures the argument correctly because it identifies that core: ethics demand not imposing medically unnecessary surgery on normal, healthy children, regardless of gender or potential benefits.

Tony is, of course, free to subscribe to whatever system of ethics he so chooses. However, to my mind he is setting an extraordinary requirement: that an intervention should not merely be medically beneficial, but must actually be necessary. If applied consistently, such a standard would mean, for example, that vaccinations are unacceptable, since they are rarely necessary.

His assessment is close, but too neat for this complicated comparison. That is the requirement I set for proxy consent to surgery. The scenario for vaccinations differs. As I wrote before, the difference rests on how the problems the interventions are meant to prevent occur. Becoming infected with measles requires no effort other than participation in society, while acquiring HIV from an HIV+ female through vaginal intercourse requires a very specific action, an action not undertaken by infants. Later in his reply, he writes about this:

This is a nonsensical argument: it is absurd to analyse the issue as though children never grow up. Peter Pan is fiction. Children grow up to become adults, and yes, that includes having sex.

Of course, to which I reply as a start: condoms. Condoms are among the many possibilities short of circumcision as an infant available to adult males, including circumcision as an adult, to reduce the risk of HIV transmission.

Ultimately the comparison to vaccines must rest on diseases like HIV rather than the other potential benefits used to justify circumcision. They roughly share some of the same characteristics. The comparison fails because, as I wrote, the way in which the diseases spread differ. For most vaccines, it is the most effective and least invasive way to stop the spread of the targeted disease. With comparable diseases, circumcision is neither the most effective or the least invasive method available.

The risk of female-to-male HIV transmission through vaginal intercourse is a significant problem in Africa. In America HIV transmission risk through sex overwhelmingly involves male-to-male transmission, from which the (voluntary) circumcision of (adult) males has shown no statistically significant reduction.

Tony's words are somewhat misleading here. There haven't been any controlled trials of voluntary circumcision in MSM yet. The American studies to date have mostly compared previously (and probably neonatally) circumcised men with uncircumcised men. Some studies have shown a statistically significant reduction, but others have not.

Fair enough on precision. However, an implicit point in my argument here stands unaltered. Assuming voluntary adult circumcision is shown to reduce the risk of all forms of HIV transmission through sex, parents can't know that their sons will be irresponsible and "need" this intervention. It's a speculation that does not need to be made for a child. He can choose it later.

Responding to my declaration that surgical risks be weighed against objective (lack of) need rather than potential benefits, Jake replies:

As Tony correctly observes, the situation we're discussing is not one in which there is an immediately pressing need for therapeutic intervention, hence the "most effective and least invasive" criteria for choosing that intervention do not apply. Instead, the situation involves a healthy child, much as with vaccinations. And as with vaccinations, we weigh the risks (adverse reaction) against the future benefits (reduction of risk of disease). Tony is of course free to apply his own ethical standard, but he should not be surprised that others choose not to follow him.

There is no need, so "most effective/least invasive" doesn't apply? Jake is begging the question he wants to answer rather than addressing objective facts. He's saying that the standard for surgical intervention on a child should be stricter when the child is sick than when he is healthy. Parents can be more speculative and exploratory with surgery for their healthy (male) children? That's ridiculous. Without objective need for an intervention, proxy consent for surgery can't be valid. With objective need, it can be valid because the child needs some form of decision made and he is incompetent to make that decision.

Setting the ability to chase potential benefits as the ethical standard opens the range of allegedly valid parental interventions to include any number of surgeries we recognize as offensive. The science becomes ungrounded by any concern for the individual child as an individual.

Unfortunately, Tony hasn't identified any of these "surgeries we recognize as offensive" that are valid when benefits and risks are properly weighed. I would be interested to learn of any that he - or anyone else - can think of.

I am not citing any particular science or surgeries because that was not my point. I am attacking a way of thinking, particularly about the ethics of circumcising healthy children, but it applies more generally. Jake is a utilitarian. I am not, precisely because of the way it permits his mixing of subjective criteria into a universal recommendation. I recognize that each person is an individual with different preferences and desires. Prophylactic (and ritual) circumcision violates that child's rights.

But to his retort, if a study were to find potential health benefits for genital cutting in a study of adult female volunteers, would that be acceptable to apply to healthy female minors? I've had this discussion with Jake previously, so I know he'd have no problem with it if parents subjectively valued the benefits more than the risks. He is wrong. Society would be (correctly) outraged at the suggestion of violating the child's rights in favor of her parents' "rights". Our anti-FGM laws would not be overturned. Those results would never be applied, regardless of the science.

Add to this the fact that parents treat the same maladies circumcision is supposed to prevent with less invasive, non-surgical methods when they affect their daughters, and Jake's argument misses the ethical case against infant circumcision because he's making the case for circumcision devoid of context and ethics. That's a case that works only if it's a voluntary decision by the adult male himself.

This paragraph makes no sense.

That paragraph is clear. We apply different standards to boys and girls. A female minor's risk of UTI is higher than that of a male minor's, yet we do not vigorously seek proof that genital cutting is the answer, nor, as I said above, would we apply it to infant girl if we could find such results. Now replace UTI with cancer. Ethically, we'd have the same approach to girls. Their genitals would be off-limits.

[Quotation of my words omitted]

If Tony had been paying attention, he would have noticed that I actually identified the three reasons why IA claimed that circumcision was unethical, and addressed each in turn.

As I've explained, Jake's version of ethics is flawed because he values only his own opinion as a viable conclusion on the subjective topic. Proxy consent requires objectivity first. A passive-aggressive insult directed at my reading comprehension does not prove that I was wrong.

As a reminder, here is what IA claim: "Doctors have a responsibility to tell parents the truth: circumcision does not prevent disease. Most European nations, with circumcision rates near zero, have lower HIV/AIDS rates than the United States."

As I read that, the second sentence seems to be presented as evidence for the first. If that is so, IA appear to be saying that the most definitive evidence can be found in between-country comparisons.

I read it a differently, based on the context of how the letter is organized. I will not defend the statement Jake objects to because I believe Intact America's statement is poorly written. I read it as saying a) studies have found that (voluntary, adult) circumcision has been shown to reduce the risk of (female-to-male) HIV transmission and b) other similar countries that do not circumcise have lower HIV rates, therefore c) infant circumcision is not the answer. I made that point in my response. Doing so in the way that he did, it's clear we're using different interpretations. I do not think Jake is wrong to call out Intact America's wording.

The risk factors among America's population are similar to those of European nations, not African nations. Our risk is male-to-male transmission and shared needles during IV drug use.

If Tony is confident in his assertions, perhaps he will volunteer to have heterosexual intercourse with an HIV+ woman. Probably not, I suspect, because of course that's a risk anywhere. The main difference, of course, is that the probability of exposure changes dramatically. Put bluntly, if you sleep with a person then your risk of acquiring HIV depends on the probability that they are HIV+.

Jake establishes a straw man here. I made a statement of fact about HIV transmission in the United States. His rebuttal is that I should be willing to have sex with an HIV+ woman because I state that voluntary, adult circumcision applied to infant males is not what we need. Presumably he means without a condom. Where have I said that unsafe sex - of any kind, with or without a foreskin - is wise? Jake's scenario is a stupid diversion.

The complications of circumcision affect individuals. Those individual have rights. We recognize this for female minors, legislating against parental proxy consent for medically unnecessary genital surgery on daughters for any reason. The ethical argument against infant male circumcision involves the equal rights concept that the same protection should be applied to males. Waskett hasn't yet made a coherent case for denying these rights to male minors.

It is not meaningful to compare female genital cutting to circumcision. Female genital cutting is a net harm, with no known medical benefits, immediate risks, and a considerable chance of permanent harm. Society passes laws to protect the vulnerable from harm, and so it makes sense to protect children from female genital cutting. But - applying the same principle - it doesn't make sense to legislate against circumcision, because there is no net harm. Most reasonable people, weighing the risks and benefits, come to the conclusion that it is neutral or beneficial.

It is meaningful to compare female genital cutting to male genital cutting because, ethically, they involve the same issue. Unnecessary surgery on a non-consenting individual is wrong. America's anti-FGM law makes no exemption for potential benefits or parental opinion. The former is, as Jake points out, not shown by studies. The latter is all that informs infant male circumcision, since an evaluation of potential benefits is opinion absent any objective indication for the child's healthy genitals. There is an obvious double standard. Girls may not have their healthy genitals cut for any reason. Boys may have their healthy genitals cut for any reason. That's the valid comparison.

To Jake's claim of "no net harm" from male circumcision, I'll repeat that it is a subjective evaluation. It is his opinion. I weigh the objective harms - scar, lost nerves, excised frenulum, asymmetrical suturing, altered functionality - from my "normal" circumcision differently than he weighs them from his (self-chosen) circumcision, but he is not me. As he was correct in deciding on circumcision for himself, I am correct in evaluating it differently for my body. Not Jake, not my parents, not "most reasonable people", not whoever else he wishes to cite who approves of circumcision. That gets lost in his utilitarian disregard for ethics on a topic without a valid objective conclusion for his position.

October 21, 2009

Hanna Rosin Is Still Wrong On Circumcision, Revisited

Hanna Rosin returns with another apologia showing her determination to remain blind to the ethics against infant circumcision.

... But now that I have done my homework, I’m sure I would do it again—even if I were not Jewish, didn’t believe in ritual, and judged only by cold, secular science.

First, interviewing and/or reading the websites of Edgar Schoen and Brian Morris is not doing one's homework. They are pro-circumcision advocates who promote bizarre theories. Two of them appear nearly verbatim in Rosin's essay.

On the larger point, she's mistaken. Cold, secular science demonstrates that an infant male's foreskin is healthy. Intervention is not indicated. The cold, secular science she refers to replaces ethics with utilitarian conclusions devoid of any concern for the child's opinion. This is inexcusable where proxy consent is involved for a medically unnecessary surgical intervention.

There's a lot of nonsense in this next paragraph, so I'll unpack it slowly:

Every year, it seems, a new study confirms that the foreskin is pretty much like the appendix or the wisdom tooth—it is an evolutionary footnote that serves no purpose other than to incubate infections. ...

No. Every year, it seems, a new study confirms that there is some other potential benefit to be chased for a minor risk. Very few studies have been done on whether or not the foreskin is an "evolutionary footnote that serves no purpose other than to incubate infections." This is her bias creeping in. She doesn't value the male foreskin, so it must have no value. This despite the clear evidence that the foreskin contains nerve endings, among the many facts that disprove her opinion. It's an illogical avoidance of the issue involved. Only the individual can draw a subjective conclusion for himself such as the one Rosin presents.

... There’s no single overwhelming health reason to remove it, but there are a lot of smaller health reasons that add up. ...

Again, this is her subjective evaluation because the boy's health is the only objective fact involved.

... It’s not critical that any individual boy get circumcised. ...

She ignores the idea of the child as an autonomous person with basic individual rights. The excuse will be the collective, which I'll dismantle momentarily.

... For the growing number of people who feel hysterical at the thought, just don’t do it. ...

This is the usual trope: If you don't like circumcision, don't circumcise your son(s). That dismisses the individual in favor of the notion that his parents' have ownership interests in this part of their child's son's body. For the male who doesn't want to be circumcised, his opinion is correct for his body. If he was healthy at the time of his circumcision, proxy consent was invalid. He can't undo his parents' decision (for their own subjective reasons).

... But don’t ruin it for the rest of us. ...

Rosin is digging deeper into her self-absorbed approach to this topic, further proving the ownership mentality necessary for her stance to appear viable.

... It’s perfectly clear that on a grand public-health level, the more boys who get circumcised, the better it is for everyone.

It's perfectly clear that on a grand public-health level, the more males who get circumcised, the better it is for everyone if our HIV epidemic ever begins to resemble the African epidemic relevant to the randomized controlled trials involving adult male volunteers that showed a reduction in the risk of female-to-male vaginal transmission. But the usual caveats apply. America's HIV situation differs from Africa's. STD transmission requires sexual activity, which excludes male minors from the target group. All other potential health benefits from infant male circumcision involve only risks to the individual and are not relevant to the collective public health angle Rosin peddles here.

Twenty years ago, this would have been a boring, obvious thing to say, like feed your baby rice cereal before bananas, or don’t smoke while pregnant. These days, in certain newly enlightened circles on the East and West Coasts, it puts you in league with Josef Mengele. Late this summer, when the New York Times reported that the U.S. Centers for Disease Control might consider promoting routine circumcision as a tool in the fight against AIDS, the vicious comments that ensued included references to mass genocide.

People who suggest mass genocide are idiots, but the ethical point stands. Without ethics, the cold, secular science Rosin presents would permit any number of offensive interventions. What could we study about cutting the genitals of adult female volunteers that we could then apply to healthy female minors at the request of their parents? How is that offensive suggestion suddenly rational when changing the gender from female to male?

There’s no use arguing with the anti-circ activists, who only got through the headline of this story before hunting down my e-mail and offering to pay for me to be genitally mutilated. ...

This is ad hominem. I haven't hunted down her e-mail. I'm not suggesting that she be genitally mutilated. Instead, I'm offering a logical, fact-based rebuttal to her personal opinions about what she wants the facts to be.

... But for those in the nervous middle, here is my best case for why you should do it. Biologists think the foreskin plays a critical role in the womb, protecting the penis as it is growing during the third month of gestation. Outside the womb, the best guess is that it once kept the penis safe from, say, low-hanging thorny branches. Nowadays, we have pants for that.

I've seen it before from Brian Morris¹, but I thought Rosin would be a bit less ridiculous. Instead, she repeats it as logic, as her best case, rather than dismissing it for the obvious nonsense it is. If the evolutionary purpose of the foreskin was to protect the penis from, say, low-hanging thorny branches, it's purpose is not suddenly irrelevant because we wear pants. The foreskin's purpose is to protect the penis, full stop. What it protects the penis from is a matter of circumstance particular to each male's life, not the level of civilization of his time.

After rehashing some of the last 140 years of circumcision history, this:

... Circumcision, it turns out, could reduce the risk of HIV transmission by at least 60 percent, which, in Africa, adds up to 3 million lives saved over the next twenty years. ...

Condoms, it turns out, could reduce the risk of HIV transmission by nearly 100%.

To the ethics, she omits that the studies involved adult volunteers. She hasn't made the ethical case for why circumcision should be forced on non-sexually active infants.

These studies are not entirely relevant to the U.S. They apply only to female-to-male transmission, which is relatively rare here. But the results are so dramatic that people who work in AIDS prevention can’t ignore them. Daniel Halperin, an AIDS expert at the Harvard School of Public Health, has compared various countries, and the patterns are obvious. In a study of 28 nations, he found that low circumcision rates (fewer than 20 percent) match up with high HIV rates, and vice versa. Similar patterns are turning up in the U.S. as well. A team of researchers from the CDC and Johns Hopkins analyzed records of over 26,000 heterosexual African-American men who showed up at a Baltimore clinic for HIV testing and denied any drug use or homosexual contact. Among those with known HIV exposure, the ones who did turn out to be HIV-positive were twice as likely to be uncircumcised. There’s no causal relationship here; foreskin does not cause HIV transmission. But researchers guess that foreskins are more susceptible to sores, and also have a high concentration of certain immune cells that are the main portals for HIV infection.

But the results are so dramatic that we must apparently discard our rational minds and circumcise infants to prevent a disease from spreading in the U.S. in a way that it doesn't generally spread now. We must do this because researchers are guessing, and look, we have self-reported anecdotal data to rely on. She's proven nothing by citing this.

Regarding the study of 28 nations, which 28 nations did Halperin choose? I can pick a group of countries that will show the opposite. The real problem is behavior, not anatomy. Rosin admits as much, indirectly, when she states that the foreskin does not cause HIV transmission. Remember, correlation does not equal causation.

Then there are a host of other diseases that range from rare and deadly to ruin your life to annoying. Australian physicians give a decent summary: “STIs such as carcinogenic types of human papillomavirus (HPV), genital herpes, HIV, syphilis and chancroid, thrush, cancer of the penis, and most likely cancer of the prostate, phimosis, paraphimosis, inflammatory skin conditions such as balanoposthitis, inferior hygiene, sexual problems, especially with age and diabetes, and, in the female partners, HPV, cervical cancer, HSV-2, and chlamydia, which is an important cause of infertility.” The percentages vary in each case, but it’s clear that the foreskin is a public-health menace.

This is the "something may go wrong" theory mixed with the "we can do this, so it must be ethical" non-standard employed in Rosin's cold, secular science. It's devoid of any context for how common those risks are, differences between minors and adults, risk factors and possible prevention and treatment options. The whole thing is a diversion, completed with the shameless fear-mongering of "the foreskin is a public-health menace."

This mundane march of health statistics has a hard time competing with the opposite side, which is fighting for something they see as fundamental: a right not to be messed with, a freedom from control, and a general sense of wholeness. For many circumcision opponents, preventive surgery is a bizarre, dystopian disruption. ...

Yes, because the opposite side is grounded in reason and objective facts. I've made the case extensively why this is true. Rosin has yet to show why this is false (in any of her attempts).

... I can only say that in public health, preventive surgery is pretty common—appendix and wisdom teeth, for example. ...

Remember, she's established her case for preventive medicine on the idea that the foreskin has no purpose, which is false. There's also recent evidence suggesting the "unnecessary" appendix has a function, proving that cold, secular science is always learning more. And she's demanded that we accept infant circumcision as a matter of public health, yet has provided no legitimate public health risks requiring infant circumcision. Phimosis, for example, is not a public health risk in any way. (It doesn't automatically require circumcision, either.)

Sexual pleasure comes up a lot. Opponents of circumcision often mention studies of “penile sensitivity regions,” showing the foreskin to be the most sensitive. But erotic experience is a rich and complicated affair, and surely can’t be summed up by nerve endings or friction or “sensitivity regions.” More-nuanced studies have shown that men who were circumcised as adults report a decrease in sexual satisfaction when they were forced into it, because of an illness, and an increase when they did it of their own will. In a study of Kenyan men who volunteered for circumcision, 64 percent reported their penis to be “much more sensitive” and their ease of reaching orgasm much greater two years after the operation. In a similar study, Ugandan women reported a 40 percent increase in sexual satisfaction after their partners were circumcised. Go figure. Surely this is more psychology than science.

This paragraph supports my contention that the value of circumcision is subjective to the individual, meaning the decision should be left to the individual who will live with the results, not his parents who invoke their own subjective preferences.

People who oppose circumcision are animated by a kind of rage and longing that seems larger than the thing itself. Websites are filled with testimonies from men who believe their lives were ruined by the operation they had as an infant. I can only conclude that it wasn’t the cutting alone that did the ruining. An East Bay doctor who came out for circumcision recently wrote about having visions of tiny foreskins rising up in revenge at him, clogging the freeways. I see what he means. The foreskin is the new fetus—the object that has been imbued with magical powers to halt a merciless, violent world—a world that is particularly callous to children. The notion resonates in a moment when parents are especially overprotective, and fantasy death panels loom. It’s all very visual and compelling—like the sight of your own newborn son with the scalpel looming over him. But it isn’t the whole truth.

She's speculating about motive in a way that borders on a return to ad hominem. It all circles back to her self-absorbed, "don't ruin it for us" mentality. She likes circumcision so I am mistaken in being angry about surgery performed on my healthy infant body. Society would've rejected that parental choice on the ethical stance I've established, if only I'd been born a girl. By now it's clear that Hanna Rosin has no intention of doing anything more than working backwards from her conclusion, avoiding the facts that challenge her opinion. That's something, but it's not the case against the case against circumcision the title of her essay promises.

¹ I'm not interested in providing Morris a direct link for search engine purposes. Read his speculation here: http://www.circinfo.net/why_are_human_males_born_with_a_foreskin.html

October 20, 2009

Science Requires Ethics

Intact America ran an open letter, as an advertisement, in yesterday's Washington Post urging the American Academy of Pediatrics not to recommend that American parents circumcise their infant sons as a strategy against HIV. [Full disclosure: I attended an event hosted by the organization and interact with some of its representatives because I support its cause.] It's a logical request, based on the necessary combination of science and ethics. A pro-circumcision advocate, Jake Waskett¹, has attempted a deconstruction of the letter, labeling it "propaganda". His support for that charge is preposterous, as any approach advocating the circumcision of healthy infant males must inevitably be, but his critique fails because he ignores the central issue involved. After a brief introduction, complete with an absurd assumption about Intact America's motives, Waskett quotes the opening paragraph:

American parents trust their pediatricians and rely on them for the best advice in caring for their children. As a matter of ethics, that advice cannot include neonatal male circumcision - a medically unnecessary, potentially risky surgery that no major medical authority in the world recommends.

I agree with this, although I'm not a fan of appeals to authority. As should be evident with the apparent intention of the CDC to recommend infant circumcision, it only takes one ill-conceived recommendation to distract from the core issue. Despite my misgivings, Intact America structures the argument correctly because it identifies that core: ethics demand not imposing medically unnecessary surgery on normal, healthy children, regardless of gender or potential benefits.

Waskett assesses this with an odd bit of snark about people inventing fire before issuing a parenthetical aside suggesting that the national medical bodies of African nations now implementing mass circumcision programs implies approval. Perhaps this is the case, which circles back to my reservation about an appeal to authority. But assuming it is not a point of fact. Still, if he's granted the point, what does this prove about Intact America's ethical argument? The risk of female-to-male HIV transmission through vaginal intercourse is a significant problem in Africa. In America HIV transmission risk through sex overwhelmingly involves male-to-male transmission, from which the (voluntary) circumcision of (adult) males has shown no statistically significant reduction. Even if this wasn't the case, the ethical issue of applying scientific research to healthy children through surgery centers on infant circumcision, not infant circumcision. That's the point Waskett ignores. His defense:

So what do we have left? A "potentially risky surgery". Well, yes, it is. There are risks, of course, albeit small. But these need to be weighed against the benefits: a reduction in the risk of certain conditions.

Finally, "medically unnecessary". Again, yes, it is. But that's not an argument against it: something can be beneficial, even advisable, without being necessary. Take vaccinations, for example: they're not strictly necessary, but they're certainly advisable.

Their claim that circumcision is unethical seems to be on shaky ground.

No, these risks need to be weighed against the need, or rather, the lack of need. The ethics of proxy consent require parents to choose a balance between the most effective and least invasive solution to remedy their child's malady. But there is no malady when the boy is healthy. Setting the ability to chase potential benefits as the ethical standard opens the range of allegedly valid parental interventions to include any number of surgeries we recognize as offensive. The science becomes ungrounded by any concern for the individual child as an individual.

Invoking the topic of vaccinations does not change this evaluation. There are similarities between circumcision and vaccination, based on potential benefits. However, the difference rests on how the problems the interventions are meant to prevent occur. For example, becoming infected with measles requires no effort other than participation in society, while acquiring HIV from an HIV+ female through vaginal intercourse requires a very specific action, an action not undertaken by infants. Comparing the two solutions as comparable for parental consent fails.

Add to this the fact that parents treat the same maladies circumcision is supposed to prevent with less invasive, non-surgical methods when they affect their daughters, and Waskett's argument misses the ethical case against infant circumcision because he's making the case for circumcision devoid of context and ethics. That's a case that works only if it's a voluntary decision by the adult male himself.

Next, Intact America requests that the AAP defend the ethics against infant circumcision rather than considering a revision in favor of the surgery since science necessarily involves ethics when applied to a person's body, particularly via proxy consent. Waskett calls this request "bizarre," despite having failed thus far to address the ethical argument made by Intact America.

Continuing:

[sic] still, more than one million American babies undergo the surgery every year driving one billion dollars in health-care spending.

And, no doubt, saving comparable figures in disease prevention.

Waskett's claim is based on speculation. Perhaps his analysis is correct, but he does not provide proof for his assumption here. We have statistics from other western nations demonstrating the incidence rates for the diseases to which he refers. Since we can analyze circumcision on these terms, "no doubt" is insufficient.

Regardless of the cost, the issue is still the ethics of circumcising healthy infant males. The individual matters, not America's males as a collective.

Continuing:

Most European nations, with circumcision rates near zero, have lower HIV/AIDS rates than the United States.

Are Intact America really so naive about epidemiology that they think that between-country comparisons constitute a decisive answer to such a question? Evidence-based medicine requires use of the best available evidence (usually randomised controlled trials), not the least (ecological analyses such as this are considered one of the weakest methodologies, and for good reason).

First, the "best available evidence" is that the infant male is healthy. No surgery is indicated or, therefore, justified. But that's nit-picking facts when it's as correct to stick with ethics.

Waskett seems to think that Intact America ignores the randomized controlled trials showing risk reduction in female-to-male HIV transmission from voluntary adult circumcision. The letter noted this fact in an earlier paragraph. Still, as I read the letter, Intact America is not making an argument about epidemiology. Rather, it is making an argument about populations and risk factors. The risk factors among America's population are similar to those of European nations, not African nations. Our risk is male-to-male transmission and shared needles during IV drug use. Circumcision protects against neither. Is that complete proof that infant circumcision in America, unlike the randomized trials involving adult volunteers in Africa, is irrelevant to the United States? No, and I don't think Intact America is suggesting otherwise. It is simply working from the central fact, which is that it is unethical to circumcise healthy infant males - who are not sexually active - to prevent a disease for which most of them will face minimal lifetime risk and for which less invasive, more effective prevention methods exist. Europe is an appropriate anecdotal case study that (infant) circumcision is not necessary to achieve the results health officials desire.

Continuing:

Furthermore, circumcision has significant risks, including infection, bleeding, impairment of sexual function, and even death. Earlier this year, an Atlanta family was awarded $2.3 million because a physician accidentally amputated much of their infant son's penis during a "routine" hospital circumcision. A Canadian baby bled to death in 2004, after being circumcised in a British Columbia hospital. In 2008, a baby from South Dakota bled to death, and his parents have filed suit against the hospital where he was circumcised, as well as the doctor who performed the surgery.

Yes, accidents happen, and of course they're tragic. But let's be sensible. If we're going to consider the risks associated with circumcision, we also have to consider the risks associated with non-circumcision. Babies die of urinary tract infections - and circumcision reduces the risk. Adults die of penile cancer (again, the risk is reduced) and of HIV (and again).

The complications of circumcision affect individuals. Those individual have rights. We recognize this for female minors, legislating against parental proxy consent for medically unnecessary genital surgery on daughters for any reason. The ethical argument against infant male circumcision involves the equal rights concept that the same protection should be applied to males. Waskett hasn't yet made a coherent case for denying these rights to male minors.

But on his demand that we include the "risks associated with non-circumcision," to an extent these must be lumped into the risks associated with living. That's sufficient since it's how we treat female minors, but it's worth noting that Waskett's argument is flawed because he ignores the context of those ailments, thereby avoiding the ethical issue of proxy consent. He ignores that alternate solutions exist for those risks associated with normal genitalia. Most infections are not life threatening and can be treated with interventions less severe than surgery. The other risks, such as HIV and penile cancer, involve causes (i.e. behavior) not directly related to the foreskin. This is the approach we take with female minors. It is the approach an ethical society would take with male minors.

¹ This is an assumption. I have interacted with Jake Waskett on previous occasions. The language, tone, and approach to the topic match what is found here. As added support, an excerpt in the entry quotes "...in favour of the surgery..." from the Intact America letter, which is a British spelling not found in the original letter. At least one other British spelling appears in the entry. Waskett is British. I leave open the possibility that I am mistaken and will correct if it becomes clear that I am.

October 13, 2009

Nancy McDermott Is Wrong On Circumcision

In replying to an essay against infant circumcision by Ethan Epstein at Spiked, Nancy McDermott attempts to defend parental proxy consent for routine infant male circumcision. She is mistaken.

The main problem with The Circumcision Discussion in general, and with Ethan Epstein’s article in particular, is the appeal to Science with a capital S to validate what is essentially a personal decision for parents. There isn’t really overwhelming evidence for or against infant circumcision, which makes this issue quite unambiguously a matter of preference, and more so than some other issues such as breastfeeding or vaccination where the scienctific research is abundant.

There is overwhelming scientific evidence against infant circumcision: the boy is healthy. Surgery on that healthy person is only unambiguously a matter of preference if the healthy person makes the decision for himself. It is not a valid personal decision for parents to make for their healthy children, male or female.

A good blogger would stop here because McDermott's case is already refuted. But there's more to say. Effectively, McDermott advocates using science without the capital E of Ethics. Would we entertain a discussion of whether or not removing the breast bud's of female minors is a valid parental decision because it might reduce her risk of breast cancer? Of course not. Yet, we abandon such critical thinking because circumcision has a long history. We ignore that science without ethics encourages us to choose the science we prefer while ignoring objective reality. Again, the child is healthy. He needs no intervention. Therefore, the child's human rights are involved, even when medical intervention is indicated. As discussed here it is the primary sole issue because the child is healthy. McDermott's argument is the usual sophistry unleashed to defend genital cutting on male children as a parental right, despite the lack of need and demand that we only extend this right to their children of one gender.

She continues:

But that hasn’t stopped Epstein from trying to use Science to support what is essentially his own particular set of prejudices. In the end, his attack on infant circumcision is not based so much on evidence but rather on a degraded notion of personal autonomy that is contemptuous of parents and reduces the whole parent/child relationship to the matter of a few inches of skin.

Defining the foreskin down as "a few inches of skin" indicates a particular set of prejudices. Defining surgery as a relationship tactic indicates a particular set of prejudices, as well.

As for being contemptuous of parents, I am. When parents engage in contemptible behavior, I will call their behavior contemptible. Since it's always worth repeating in this discussion, the child is healthy. Performing surgery on him (or her) for the parents' subjective reasons is unethical because it violates a basic human rights principle: Performing medically unnecessary surgery on a non-consenting person is wrong. Where facts differ from any of the conditions involved in that principle, the discussion changes to proxy consent. But circumcision as understood in this essay involves all of the facts involved in the principle. Proxy consent is not valid.

Referring to Epstein's essay, McDermott continues (footnote removed):

Take for instance his attempt to establish – or rather to assert – that male infant circumcision is on a par with ‘female circumcision’. It’s a comparison that defies even a basic familiarity with human anatomy. ‘Female circumcision’, or Female Genital Mutilation (FGM) as it is usually called, involves the removal of some or all of a woman’s external genitalia and is associated with side effects like intense pain, infection, haemorrhaging, infertility and urinary incontinence. Comparable surgery in a man would involve the removal of most of the penis and the scrotum. But male circumcision as it is currently practiced consists of the removal of the foreskin and nothing else. Statistically it is a very safe procedure with few complications (in some cases, there may be minor bleeding or a local infection).

The moral equivalency exists because medically unnecessary surgery on a non-consenting person is wrong. Gender is irrelevant. Extent of damage is irrelevant. The World Health Organization defines female genital mutilation as "procedures that intentionally alter or injure female genital organs for non-medical reasons." The intent is generally different between male circumcision in America and female genital cutting in other cultures, but a well-intentioned act can still be objectively harmful. Outcome matters. And male circumcision meets the definition applied to female genital cutting, since the male child's genitals are intentionally altered for non-medical reasons." There is usually a difference in degree, but there is no difference in kind.

Given that male genital cutting matches the definition applied to female genital cutting, it's crucial to explore how McDermott is under-informed about FGM. As it's typically practiced, it involves removal of some or all of a female's external genitalia. But FGM is defined to include "all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area." These (less commonly practiced) forms are similar in enough ways to male circumcision to make the point. Parents who force it on their daughters often give similar subjective reasons for both procedures. Yet, our anti-FGM laws make no distinction for extent of cutting or personal preference involved in the parents' decision. The focus is on the autonomy (and health) of the minor, which is where the focus should be.

Yet, it's easier to explain why McDermott is wrong. How does she arrive at the implied conclusion that removing a male child's foreskin is not "the removal of some or all" of his external genitalia? Implicitly (and incorrectly) positing that the foreskin and its removal are trivial isn't enough. She ignores the truth that, as surgery, circumcision is harm. Instead, she relies on self-reporting studies that she believes support her stance (footnote omitted):

Epstein doesn’t do much better when he tries to show evidence for psychological trauma and sexual dysfunction as a result of circumcision. He relies on a 2002 paper written by self-proclaimed ‘intactivists’ which indicates that some men enjoy sex less after circumcision. Had he more objectively investigated what he says is ‘quite evidentially true’, he might have come across any number of studies that show the opposite. My favourite is a large-scale study from 2008 (with over 4,500 participants) in which an overwhelming majority of Kenyan men reported no difference in sexual satisfaction or function after their circumcisions.

What is incompatible in comparing a study that indicates some men enjoy sex less after circumcision and a study that shows an overwhelming majority of men reported no difference? "Some men" and "overwhelming majority" are both synonymous with "less than 100%" for the purposes of the ethical discussion of medically-unnecessary child circumcision. Some males will not be happy being circumcised. I am not. Some men will suffer more than the standard, "acceptable" damage. The issue is about an individual right, not a right based on parental desires.

Continuing:

It is striking that midway through Epstein’s article the CDC’s proposal to ‘promote’ infant circumcision mysteriously transforms into a plan to ‘mandate’ infant circumcision. This is not a slip and it’s not just that Epstein has got his facts wrong (although he has). ...

I'll pause here to make the point that I am not defending Epstein's article. Were I to write about it, I'd call out the same flaw McDermott notes about the CDC's intentions, as I wrote when the CDC news stories broke in August.

... Rather he makes this change in terminology because he isn’t really talking about the CDC at all any more. He’s talking about parents. For anti-circumcision activists, all infant circumcision is mandated in the sense that infants do not consent to it.

Exactly.

In what seems an attempt to defend her indifference to what the boy doesn't need and may not want, her next paragraph demonstrates how she's failed to grasp this fundamental aspect of the ethical case against infant circumcision.

On one level Epstein is right. It is of course impossible for an infant to consent to anything, and parents make decisions large and small on behalf of their children all the time. Some of these decisions affect their future and many are far more difficult than the question of whether or not to have your infant circumcised.

That some decisions parents make are "far more difficult" does not validate parental proxy for infant male circumcision.

In the second excerpt above, McDermott mentions the parent/child relationship. This inevitably leads to a mistake that advocates of infant circumcision, or at least of parental choice, make. McDermott is no different:

Many of the choices we make as parents profoundly affect our children. But when we look back at our own lives it is often things that didn’t concern us directly at all that had the greatest impact - things like parents’ decision to divorce, to change jobs, or to emigrate. As children we rarely have any say and yet we manage to adapt and often to flourish. One of the major reasons we are able to develop this resilience is because we can depend on our parents. It is the parent/child relationship - each one unique and dynamic, a complex mix of love and trust, and mutually crazy-making - that creates the sense of inner confidence that helps us learn shape our own destinies.

By counterpoising the ‘personal autonomy’ of an infant to the judgment of his parents, Epstein and others who campaign against circumcision reduce the relationship between parents and their sons to one moment; a moment that forever defines the child as victim and the parent as victimiser regardless even of what the boy himself thinks about it later in his life. Once a victim, always a victim.

McDermott's shift from discussing the parent-child relationship to the parent-son relationship reveals the flaw in her thinking. There's a key distinction because she talks in generalities to establish parental authority before shifting to a specific case in which she omits a gender from consideration to reach her preferred outcome. If parents have a right to choose that is superior to the personal autonomy and health of their sons, that same right exists superior to the personal autonomy and health of their daughters. She rejects objective health and risks in favor of subjective decisions by parents for their sons, yet accepts objective health and risks as a defense against subjective decisions by parents for their daughters. That right doesn't exist, but if it did, she's being contemptuous of the parents of daughters because she refuses to let them exercise their right. She'd deny that, but regardless, it's clear she started with her preferred outcome and worked her way backwards to find only the relevant facts she needed.

She concludes:

There are all sorts of reasons why parents do or don’t circumcise their sons. For some it is the embodiment of their faith, for others it is simply custom. For some the thought of subjecting their child to any unnecessary pain or alteration is unacceptable. The important point is that the choice takes place within the context of the parent-child relationship. ....

Again, the choice she's defending takes place between the parent-son relationship. She's established this separate category, incorrectly as I've shown, without offering an explanation for why this is legitimately a separate category beyond an incorrect assumption that the removal of some or all of a female minor's external genitalia is offensive in a way that removal of some or all of a male minor's external genitalia is supposedly not.

...The CDC is not, as Epstein implies, planning to circumcise every male infant in the United States, but the change in its recommendation, just like every other official pronouncement about the right way to raise children, should be greeted with scepticism. Not because, as Epstein argues, it might lead parents to make a wrong choice, but because it questions their right to make choices in the first place.

Somehow I suspect she doesn't believe we should be skeptical about the official pronouncement (i.e. a law) from the United States Congress criminalizing the parental "right" to choose female genital mutilation. But we are not to question the parental right to make that choice for sons, with circumstances and reasoning explicitly rejected for female minors. Her essay is a self-absorbed excuse for parents and their made-up right to impose their whims based on irrational traditions and willful ignorance.

September 08, 2009

Religion By Scalpel Is Not A Parental Right

Andrew Sullivan weighs in on the CDC circumcision mess:

... I guess I was an early obsessive on this. As readers know, my position is simply that no parent has a right to permanently mutilate a child for no good reason. Scar tissue should be a personal choice. Would we approve of parents' tattooing infants? The entire thing is an outrage and should be banned outright with a religious exception for Muslims and Jews.

Damnit, no.  The entire thing is an outrage and should be banned outright.  If it's wrong for parents to mutilate a child for no good reason, and it unequivocally is, permitting an exception for parents to mutilate their children because their god says they must mutilate their children only legalizes no good reason.  Scar tissue should be a personal choice, unless your parents believe their god tells them to sacrifice your foreskin?  That's incoherent.  Favoring one subjective, non-medical reason over another subjective, non-medical reason for surgically altering (i.e. mutilating) a child is indefensible.

It is also objectively flawed on its practical point.  Let's assume the government finally acknowledges that boys deserve closer-to-equal protection that girls already receive, with closer-to-equal being the only way to admit that federal law currently prohibits genital cutting on healthy female minors for all subjective, non-medical reason, including religious reasons cited by parents.  Either the Congress or the courts must embrace this closer-to-equal protection.  What will stop parents from claiming religious requirements if they want to circumcise their sons?  How will the government verify the real Jews from the temporary Jews or the real Muslims from the temporary Muslims? Will the government intervene on matters of theology when Christian parents continue incorrectly claiming that Christianity endorses (or requires) infant circumcision? The only result will be that this hypothetical prohibition on the non-ritual circumcision of male minors would be struck down.

This all-too-common charade only tricks people into thinking they're being tolerant of religion. Yet, whatever your overall opinion on religion, here religion deserves explicit condemnation.  I'd rather engage reason where it involves what one person may do to another. Circumcision for non-medical reasons, including religious adherence, is purely subjective.  Scar tissue should be a personal choice.  It must therefore be left only to the individual exercising his religious freedom to circumcise himself. Or not.

Update: Mr. Sullivan responds to a reader's e-mail (emphasis added):

The reason I don't follow this to its logical conclusion is that I just cannot imagine trying to enforce a total legal ban on it given the religious outrage among Muslims and Jews it might provoke. And I do make exceptions for religious liberty that I don't for other issues, because I believe very deeply in the right of people to figure out their ultimate purpose in life without the intervention of the state. So I restrict myself to mere venting about what seems to me to be an irrational and barbaric relic.

On the first sentence, he's right. Enforcement would be difficult. But enforcement is a separate issue. Its difficulty may make the law largely impotent in the years immediately following its introduction, but that is not a valid reason to avoid enacting the legislation necessary to protect the rights of male minors. When those rights are acknowledged, as we've acknowledged for female minors for all unnecessary genital cutting, other methods of enforcement (e.g. lawsuits) become more likely, which will eventually act as a deterrent and shape the culture.

However, the fundamental problem with Sullivan's approach rests in his notion of religious liberty. Religious liberty involves letting a person "figure out their ultimate purpose" through mutilating their own genitals without state intervention. There is no liberty in letting people mutilate another's genitals. Circumcising another person is not a right, and protecting individuals from unwanted physical harm is exactly the purpose of the state. This is true even when - perhaps especially when - the harm is carried out by well-intentioned parents searching for their ultimate purpose. What about the child's ultimate purpose? That may include a preference for normal genitals. It probably will include a preference for normal genitals, if he's left his choice. Instead, Mr. Sullivan's defense of parents imposing ritual circumcision respects magical thinking more than reason and objective facts.

August 31, 2009

Meta Update

The plethora of circumcision posts will cease soon and other blogging will return. Not yet.

Talk About The Issue, Not Rush Limbaugh

I'm probably supposed to deal with this:

Limbaugh then elaborated on the reference to him in the lyric. "I would remind the rapper Jay-Z: Mr. Z, it is President Obama who wants mandated circumcision. That means if we need to save our penises from anybody, it's Obama. I did not know I was on anybody's balls, either. I'm happy to know that they think I am, though." The mention of Obama is in reference to the fact that the Center for Disease Control is considering recommending circumcision to high-risk adult men to reduce the spread of HIV, according to The New York Times.

Rush Limbaugh is a hack using controversial buzzwords because he knows it will get him attention, which is all he wants. He's a deejay, not a political thinker. Using his nonsense for political arguments on any side of any debate is stupid.

With that out of the way, Ed Brayton has a post in which he begins:

The record of demagoguery and lunacy from the right wing continues. The CDC is considering -- just considering, mind you -- adopting a policy to encourage -- just encouraging, mind you -- people to have their children circumcised on the grounds that it reduces the risk of disease. Run that through the silly straw prism of right wing spin and it magically becomes "Obama is going to force us all to cut off our genitals!"

Fine, fair enough. Again, Rush Limbaugh is a moron. But Mr. Brayton links to an article that unfairly maligns Ed Morrissey's post about circumcision and the CDC's potential recommendation that I used yesterday as a starting point for discussing single-payer and circumcision. Whatever other issues Mr. Morrissey may have in how he presents political arguments, he was correct in the suggestions of his piece. Any other interpretation is a failure by the reader to interpret his words using their common meanings. As he wrote:

Why should the CDC push circumcision at all? The government has no business being in the middle of that decision. Under ObamaCare, however, when the government starts paying more and more of the health-care tab, they will point to ambiguous cost savings down the road — in this and other cases, decades down the road — to pressure Americans into surrendering their choices now.

As I mentioned in my entry, he unnecessarily cluttered his argument with the term "ObamaCare," but other than that, I can't find anywhere he mentioned that the government would force circumcision on anyone. "Pressure" does not mean "force". The writer at Salon directly, and Mr. Brayton indirectly, are undeniably wrong.

Yet, Mr. Brayton's post generated this comment:

... While I think the net effect of such a policy would be detrimental, to equate it with forced circumcision is BAT SHIT INSANE. ...

To equate a recommendation with forced circumcision is not BAT SHIT INSANE. I've written this several times over the last week, but it's worth repeating here: For the circumcised male, why does he care whether circumcision is mandated by the government or merely by his parents? The result - forced circumcision - is the same for him. Eliminating the choice of a healthy child is the issue, not who forces the circumcision.

We can and should rebuke those like Limbaugh who offer absurd suggestions of government-mandated circumcision as a result of health care reform. It's political nonsense intended to distract. But we mustn't falsely accuse someone of making that argument who hasn't, in fact, made the argument. Doing so is no less a distraction from the legitimate issues.

**********

From another comment to the Ed Brayton post:

You can count on Limbaugh to say something stupid, but the Ed Morrissey quote is right. CDC guidelines are pressure on doctors and patients. They are supposed to be. The real problem with the Morrissey piece is the following:

"Why should the CDC push circumcision at all? The government has no business being in the middle of that decision."

That is wrong. The point of the CDC is to study the spread of infectious disease and recommend the most effective ways to slow or stop the spread.

As Mr. Morrissey wrote in the paragraph before the one I excerpted above:

I’m neutral on the issue of circumcision, which has become a controversial practice, but find this idea of interventions very, very odd. In the first place, circumcision does not provide an immunity to STDs, not AIDS or anything else. Studies indicate that circumcised males may have less danger of acquiring an infection, but as the NYT points out, that’s from heterosexual relations — a very minor channel of AIDS communication in the US. Men have much better choices than circumcision for avoiding HIV infection, including the use of condoms (still not a perfect defense, but better than circumcision), refraining from intravenous drug use with shared needles, avoiding high-risk sexual practices altogether, and so on.

Any recommendation to circumcise infant males to reduce the risk of HIV is unethical because it encourages genital cutting on a healthy, non-consenting individual. It is also stupid. Infant males are not at risk of HIV now, and will be at little risk of the only type of transmission (female-to-male) that voluntary, adult male circumcision has been shown to reduce when they begin having sex, even if they do not use condoms, which no one is suggesting they may do after circumcision. Like WHO and UNAIDS, the CDC is considering recommending infant circumcision because they know such recommendations convince parents. If they were confident that men would embrace it, they'd focus on adult volunteers. They know that's a dead-end for mass acceptance, so they recommend it for those who can't say no. It is not force by government, but when told to a receptive audience acting on behalf of another, the difference is in tactic, not outcome.

August 30, 2009

Matt Steinglass Is Mistaken On Circumcision

In the interest of context for this post, Chris Bodenner did what Hanna Rosin didn't, which is to apply critical thinking to the circumcision question. He wrote:

Studies are a red herring, however, when it comes to the ethical part of the debate. Even if there are no discernible differences between cut and uncut on average, there are still many individuals who are better or worse off from a procedure their parents imposed. As one reader puts it:

It’s my dick. It’s my dick. It’s my dick. It is no one else’s dick but my dick. And I should have the choice to circumcise it when I am old enough to make that decision.

Matt Steinglass reacts:

Let me reassure this guy: no one is planning to do anything to his dick. Assuming, that is, that he is more than 8 days old. But with respect to the practice of circumcision, the important point is this: he’s my son. Not yours. Parents have the right to decide on medical treatment for their children, presuming such medical treatment is not actively harmful. And parents have the right to include their children in cultural rites and practices, again presuming no harm is done.

Proxy consent is valid where medical treatment is indicated (i.e. necessary). Parents do not have a right to impose medical treatment - in this case, surgery - because they like that medical treatment, for whatever reason they value it. This is precisely because it fails the test Steinglass establishes: it causes harm. Circumcision is surgery. It removes healthy, functioning tissue. There is scarring. There is an inherent risk of further complications, starting with "excessive" bleeding and infection and extending all the way to death. The more extreme complications are, of course, rare, but the risk itself is a form of harm. Parents cannot know if their son will be the statistic. Good intentions are not a substitute for objective criteria.

He continues:

What, then, of female circumcision? Well, I understand, perhaps wrongly, that there are some forms which are not particularly medically invasive, and which do not entail significant medical consequences. I think that such forms of female circumcision are a matter of cultural practice that should be left up to parents to decide. The more invasive forms of female circumcision entail serious negative medical consequences. Obviously that's not cool. And female circumcision is carried out on girls aged 7 to 12 or even older; at that age, the child gets a vote, too. In any case, this doesn't have much to do with anything, because we're talking about a medical recommendation.

I'll address his strange tangent on female genital cutting in a post script. For now, I'll point out that his criteria fail because the cultural genital cutting is not a medical recommendation backed by need, regardless of the child's gender. Medically unnecessary genital surgery on an unconsenting individual is unethical. Again, it causes harm in 100% of cases for no objective benefit or attempt to correct a genital malady. The intervention is indefensible.

He concludes:

... Men who are circumcised don’t complain about it. There may be some vanishingly small number of guys who are upset about the fact that their parents circumcised them. It’s a weird thing to be upset about. The whole issue of treating this as some kind of mutilation of a rights-endowed human being who should be allowed to decide for himself seems to me like an insane metastasis of the American fixation with individual rights-based ideology. Children are born into families. Those families have cultures and beliefs, and are entitled to make decisions about how their children will be treated, shaped, and raised.

He perceives no harm and thus dismisses the individual making the rights-based claim against something he, Matt Steinglass, thinks is a "weird thing to be upset about". That tells us nothing because it's about Matt Steinglass, not circumcision. He writes only of culture and family without considering that the male may not value that culture or that circumcision is objective harm.

Yet, he's not in favor of families deciding how their children will be treated, shaped, and raised without limits. He stated that he believes parents have the right to make decisions as long as it's not actively harmful to the child. He is making a rights-based argument that centers on the child possessing certain individual rights. There are limits to how much culture may play a role. This makes the role and influence of the family and culture irrelevant here; his claim hinges first on the merits of circumcision as surgery on a healthy child. It fails for the reasons I've stated, which prevents moving to cultural considerations. It's important to remember that he implicitly agreed to that test because of his caveat. He probably disagrees that circumcision is objective harm. He is wrong, if he does, but he hasn't bothered to attempt the defense. Instead, he is essentially proposing that subjective preferences are valid for parental decisions as long as the parents believe them to be culturally valid. That's madness.

**********

Post Script: To his credit, I suppose, his paragraph on female genital cutting shows that he is consistent in his error. But I'm not sure why he thinks that girls aged 7 to 12 or even older get a vote. Is he saying they do or that they should? If it's the former, he is mistaken. If it's the latter, we limit the rights of children to the extent that we deem them capable of consenting. In this "ideal" world where children are asked before their parents surgically alter their healthy genitals, is a 7-year-old competent to make that permanent decision without undue influence? More importantly, do we believe parents will refrain if the child rejects it? Is the child to be considered potentially opposed to genital cutting only if she's old enough to voice opposition, whether or not she could reasonably be expected to comprehend the full implications? Is there a similar age for male minors?

The shorter version here is that I don't think he thought that paragraph through before he posted the entry. It's incoherent.

Insults Instead of Inquiry

Robert Stacy McCain blogged about Hanna Rosin's first circumcision post at the Daily Dish:

She dares defend circumcision while guest blogging at the site of the world's foremost foreskin fetishist, Andrew Sullivan.

"Male genital mutilation!" scream the connoisseurs of uncut, preservationists of the precious prepuce.

Get over it, people. Only porn freaks and gay men -- having ample opportunity to comparison shop, as it were -- obsess so fanatically over the difference. ...

Is this typical of McCain's writing? Rather than deal with the issue up for discussion, he smears Andrew Sullivan, which would be bad enough if Mr. Sullivan had any direct involvement in Mr. Rosin's entry. That Mr. Sullivan is not involved in the post and yet is the direct target of the smear shows an appalling lack of class. But he was only having "some mocking fun", as he writes in a follow-up post, because he "knew" Andrew Sullivan to be a foreskin fetishist. More on this in a moment.

... As I was taught in commercial design classes 30 years ago, form follows function, and familiarity with the fact of foreskinless functionality (i.e., I've fathered six kids) indicate my circumcised state is entirely adequate to the rigors of the task.

This proves what? I'm not aware of anyone making the claim that circumcised men can't have sex or that humanity will die out because circumcision causes sterility. This is a pointless diversion. "My penis works after circumcision" proves nothing about the merits of infant/child circumcision because it's a "comparison" of one data point specific to one individual.

The advantages in terms of hygiene are well-known, and tend to be especially appreciated by mothers who have a difficult enough time getting boys to bath, much less to wash their winkies with health-conscious care. ...

The advantages in terms of hygiene are achieved easier with basic hygiene methods (i.e. soap and water), which are still required after circumcision. McCain's error likely centers on his apparent ignorance of human anatomy. The foreskin adheres to the penis at birth and will not separate for many years. This protects the penis. The normal separation process may last late into puberty, long after mothers have ceased washing their sons' genitals. Not only is there no need to go digging for dirt, it is potentially harmful to do so. Not that that stops parents from permitting doctors to forcefully break the natural adhesion in order to circumcise.

As for the throwaway point about circumcision easing the job of mothers, any parent who circumcises their healthy child to make their job easier is a bad parent. Child care is difficult? Don't have kids. Choose to have kids and you discard your right to place your laziness first.

Back to his claim about fetishists:

... And it is certainly my impression -- based on comments whenever the subject is raised -- that women generally prefer what we might call the kosher pickle.

If there are fetishists, which side are they on? Is it those who advocate for each male to keep his normal genitals and choose for himself for his reasons or those who believe that parents may impose unnecessary surgery on their son's genitals because they believe his future partner(s) will find his circumcised penis more sexually appealing? A woman can believe a man with a surgical scar on his penis is sexually preferable, yet it is those who state that the foreskin is a normal part of the penis, and each male should decide for himself, who are the fetishists? With this smear, McCain shows nothing more than an apparent character flaw deployed to mask his lack of curiosity.

He continues in his follow-up post (linked above):

Being quite happily married for 20 years, after having previously spent more than a decade as an equally happy and reasonably popular bachelor, I protest any suggestion that I really give a damn about anyone else's penis but my own. While quite satisfied with my own equipment, I think it unseemly that I should boast of its merits, or to cast aspersions on the equipment of others.

What obtrudes here -- and it obtrudes from only one direction in the present discourse -- is the Foreskin Lobby's repeated assertion that the circumcised penis is "mutilated" or in some other way inferior to the unmodified phallus.

I'm happy that he's happy with his circumcised penis. I do not intend to waste my time trying to convince any circumcised male that he needs to be unhappy and wish that he hadn't been circumcised. I'd gain nothing from such an endeavor, and it's unnecessary to my logical and ethical case against circumcision. What each male decides for himself is what's valid. No one is suggesting he has to give a damn about anyone else's penis. But he needs to give a damn about the males who will give a damn about their own penises being altered by their parents without medical need.

McCain's position, like most Americans, is that parents can decide and whatever they decide is fine, for whatever reason. It's not. The child is healthy. He doesn't need surgery. The legitimacy of proxy consent ends there. This should be blindingly obvious, especially when considering the inane, offensive reasons many parents give. As McCain highlights without awareness with his reference to women's stated preference, parents circumcise based on nonsense. They don't know what their son's future partner(s) will prefer or whether he would want to have sex with someone who would reject him for having normal male genitalia. There is no possible defense for non-therapeutic infant male circumcision. That is the issue, not that Robert Stacy McCain likes being circumcised or that I hate it.

So, are those who derogate the foreskinless phallus as "mutilated" expressing some sort of religious bigotry? I hesitate to suggest such a thing, but sincerely wish that these barbaric aficionados of heathen penises would cease inciting unseemly debates over a subject so offensive to so many.

I am not surprised that someone who would trot out the fetish smear - in mocking fun, of course - would also attempt the more offensive smear that having a problem with infant circumcision is just a charade for anti-Semitism. There is no problem with circumcision as a religious rite, only with circumcision of children as a religious right. An adult may choose circumcision for himself for religious reasons or any other reason he deems worthy. And, yes, I'm aware of what the Old Testament says about circumcision. I also know what it says about slavery and adulterous women and so on. Civil society does not permit those, either, because we grasp that individuals have rights. What someone would choose for himself may not be what someone else would choose for him. The only valid option is to default to the individual's choice. Hence, no circumcision of healthy children.

**********

Because it's there... He concludes his original entry with this:

Those who prefer the sword-and-scabbard setup are perfectly entitled to their preference, ...

I'm not entitled to my preference, am I, because society allowed my parents to surgically entitle their preference on me? This is the point McCain seems determined to miss.

... without casting aspersions upon those of us who've forsaken the sheath and keep the blade ready. "Mutilation," indeed!

Without casting aspersions... Fascinating. Those who resort to name-calling are always the most thin-skinned, aren't they?

Single-Payer and Circumcision in America

In my second response to Hanna Rosin's posts on circumcision at The Daily Dish, I closed with this:

As a circumcised male, why do I care whether circumcision is mandated by the government or merely by my parents? The result - forced circumcision - is the same for me. Basically, Rosin engages in the "if you don't like circumcision, don't circumcise your son" defense. This is wrong. The case against circumcision centers on the boy as a (healthy) human being, not the boy as a son of parents making a choice.

This is the core of the ethical refutation of prophylactic infant male circumcision. Proxy consent cannot be justified on any grounds because the surgery is unnecessary, permanent, and carries an inherent risk of damage beyond what is deemed acceptable. On the last point, remember that no one considers the boy's potential future disagreement with society's definition of acceptable.

Ms. Rosin's passage that prompted my comment involved the question of government-mandated circumcision. The CDC is not recommending that, of course. My point stands because, to the circumcised child, an influenced decision is no better than a required non-decision if he does not wish to be circumcised. But it does raise an interesting point for the current debate over health insurance reform that I've attempted to make in the past. From Ed Morrissey:

I’m neutral on the issue of circumcision, which has become a controversial practice, but find this idea of interventions very, very odd. In the first place, circumcision does not provide an immunity to STDs, not AIDS or anything else. Studies indicate that circumcised males may have less danger of acquiring an infection, but as the NYT points out, that’s from heterosexual relations — a very minor channel of AIDS communication in the US. Men have much better choices than circumcision for avoiding HIV infection, including the use of condoms (still not a perfect defense, but better than circumcision), refraining from intravenous drug use with shared needles, avoiding high-risk sexual practices altogether, and so on.

Why should the CDC push circumcision at all? The government has no business being in the middle of that decision. Under ObamaCare, however, when the government starts paying more and more of the health-care tab, they will point to ambiguous cost savings down the road — in this and other cases, decades down the road — to pressure Americans into surrendering their choices now. [ed. note: surrendering the choices of their children]

Apart from unnecessarily cluttering the single-payer issue with the "ObamaCare" phrase, this is exactly right, I think. How often do we need to see the public health community ramble on about the cost-benefit analysis "proving" that the net effect of prophylactic infant male circumcision is positive? How many lies pretending that non-essential and non-functional are synonyms will be necessary before we accept that not everyone shares the same view about what individuals should do and have, when those same people so often prove that they mistake their opinion for fact? Those people are at least as likely to make it to positions of power as anyone who considers the child's lack of need and possible future objections.

It's useful to highlight that most countries with an explicitly single-payer health care system have infant male circumcision rates that don't approach 10%. Of course. But we can't dismiss that the rates are greater than 0%. We must consider why.

I think the question of why narrows to culture. American culture places a high, irrational value on circumcision and its alleged wonders. Whether it's the perceived health benefits for diseases that are already unlikely in a normal human state or a fear that schoolmates and sexual partners will laugh at him if he's normal rather than common, we don't evaluate circumcision factually. Ms. Rosin demonstrated this when she wrote that calling circumcision surgery is "a bit of an exaggeration." No, it's not, but our society possesses a strong anti-curiosity attitude on the topic. As Mr. Morrissey noted, the New York Times article provides all the necessary data to show that the CDC's thinking is irrational. Yet, it's picked up by people like Ms. Rosin who uncritically regurgitate only the parts they like and declare the resulting subset of findings uncontroversial. This is the low level of discourse in America surrounding circumcision and children.

If America had implemented a single-payer system at the same time England created its system, we could make a one-to-one comparison and the incidence of circumcision today would likely be close. But we didn't. Instead, we have 60 additional years of circumcision to defend and justify. We have irrational beliefs to refute, should those holding those beliefs be willing to question them. We have a society that "knows" the foreskin is "just a flap of useless skin" and isn't interested in hearing anything to the contrary, no matter how logical or based in scientific proof. A majority of our society still believes that the individual child is in the care of his parents for his medical decisions without a thought that this non-therapeutic surgical intervention is (social) experimentation, not medical care. The national discussion becomes about what people want to believe, not what is true. Cost is not a primary concern.

**********

Patrick Appel posted the Ed Morrissey link at The Daily Dish, where I found it. Mr. Appel writes:

The CDC is thinking of promoting circumcision, not requiring it. Whether or not you agree with the procedure, this controversy has nothing to do with health care reform. If single-payer leads to more circumcision, then how come America has among the highest rates of circumcised men in the world, much higher than most if not all countries with socialized medicine?

Mr. Appel makes the same mistake. The argument isn't that single-payer leads to more circumcision. The argument is that American single-payer will not lead to a decrease in male circumcision. Either the system will pay or parents will pay. My view is the former because public health officials invariably think about the public rather than the individuals in the collective and politicians do not have the moral framework to say "no" to the inevitable backlash that would occur. Without legal reform recognizing the same rights for boys that we've already codified for girls, circumcision will continue in America, regardless of who pays.

August 26, 2009

Hanna Rosin Is Still Mistaken On Circumcision

Hanna Rosin summarizes the responses to her circumcision post from yesterday "into three basic categories":

1. How can we do this to a child without his consent? There are so many things we do to children without their consent - change their school, banish their friends, give them drugs, abandon and neglect them. Removing a foreskin should not even fall in the top 20 ways to ruin your child's life.

Right, ethics. She again fails to address this valid concern. Stating that "X is worse than Y" grants no legitimacy to Y.

2. "Foreskins are, well, fun," writes one gay reader. My authority here is obviously limited. That said, all that research of specific areas of male sensitivity (Andrew cites some here) has always struck me as dubious. Erotic pleasure is a rich and complicated thing. Specific percentages of sensitivity can't possibly sum up the experience.

Those last two sentences are true. Yet, she's said nothing in defense of infant circumcision with either statement. Even if she'd explained why the research of specific areas of male sensitivity strikes her as dubious, what would that prove about infant circumcision? An extension of the ethical argument she's failed to confront involves each individual deciding what constitutes preferred pleasure and sensitivity from and for his normal body. Erotic pleasure is a rich and complicated thing unique to the individual. Specific percentages of sensitivity evaluated by another can't possibly sum up the experience for the individual.

3.Preventative surgery is a "bizarre notion." This is somewhat more convincing. But for one thing, "surgery" is a bit of an exaggeration. We certainly cause infants minor pain for the greater public good many times, in the form of vaccines. It depends, I suppose, whether you consider HIV and STD's a widespread public health crisis, or something affecting only a very few. I could get into the specifics of the research here, but I won't.

Why is surgery in quotes? It is not an exaggeration to call circumcision surgery. Even her source from yesterday's article, WebMD, defines circumcision as "the surgical removal of the foreskin, the tissue covering the head of the penis." If there is a risk of death, no matter how small, circumcision is surgery. Her statement suggests a lack of curiosity on the subject for anything beyond what she wants to believe.

The vaccine argument is interesting and related. However, circumcision is the (surgical) removal of healthy, functioning tissue. The associated pain is a separate, secondary aspect for consideration. Our ability to control pain and its temporary presence are not defenses for performing the offending surgical procedure. Controlling pain does not render the intervention humane.

Nor are a boy's genitals subject to the alleged needs of the public good. STDs require specific, individual actions. Those are actions that infants will not be undertaking for many years. When they begin engaging in those actions, they must use condoms, regardless of whether or not they still have their foreskin. Conveniently, a condom's effectiveness is considerably higher than that of circumcision.

On the specifics of the research, it would be useful for her to state them. I'll probably agree with her. It's not necessary, though, because the discussion must circle back to ethics because she's advocating circumcision on healthy infants, not adult volunteers. What we can do is not synonymous with what we should do.

**********

I didn't include this in my objection yesterday because it disappears as an issue once we get the question of infant circumcision correct, but it's an interesting point to pursue because a willingness to comprehend circumcision from perspective of the child's rights is essential to ultimately grasping why circumcision is wrong. From her entry today:

..., my post defending circumcision taps into the current fears about "big government trying to mandate certain types of medical procedures," as one reader wrote in.

As a circumcised male, why do I care whether circumcision is mandated by the government or merely by my parents? The result - forced circumcision - is the same for me. Basically, Rosin engages in the "if you don't like circumcision, don't circumcise your son" defense. This is wrong. The case against circumcision centers on the boy as a (healthy) human being, not the boy as a son of parents making a choice.

August 25, 2009

Hanna Rosin Is Mistaken On Circumcision

Hanna Rosin, guest-blogging for Andrew Sullivan, attempts to dismiss opposition to yesterday's news about the CDC potentially recommending infant male circumcision.

But the procedure is only "controversial" because people have emotional, psychological and religious reactions to it. Scientifically speaking, it's not remotely controversial. ...

Ms. Rosin's statement is nonsense because she ignores the ethics of implementing the findings. Her statement is nonsense because it ignores the evidence-based reality for infant males. The child's genitals are healthy at the moment of surgery. This is not "emotional," it is fact. Potential benefits do not make the surgical intervention on healthy infant males any more defensible.

Ms. Rosin continues:

... The anti-circumcision sites always refer to the American Academy of Pediatrics' 1999 policy statement on circumcision, which declined to recommend the procedure. But that statement was issued before the most compelling studies emerged about the role circumcision plays in reducing the risk for transmission of HIV and other STD's. ...

The "most compelling studies" from Africa were performed on adult volunteers, which is the key point before we get to an assessment of the significant differences in the HIV epidemics in sub-Saharan Africa and the United States. The ethical issue can't be resolved simply by noting that American culture already values the circumcision of males. American culture gets it wrong on what should be permitted on healthy children who do not need medical intervention and can't consent to cosmetic surgery. Proxy consent must require medical need first, and medical ethics should demand only the least-invasive effective treatment for sick children. Prophylactic infant male circumcision fails both standards.

Ms. Rosin later acknowledges the differences between Africa and the United States, but she seeks to pretend that "the evidence is still pretty strong, and even stronger for STD's" qualifies as a rebuttal. It doesn't. The only supported suggestion is that adult male circumcision reduces the risk of female-to-male HIV transmission. Even if that accurately described the American situation, which it doesn't, wasting finite medical resources on infant males who will not be engaging in any sexual activity, protected or not, for many years is asinine. And unethical, since we must loop back to the evidence-based reality that healthy infant males do not need circumcision.

**********

At the end of her post, Ms. Rosin raises a separate issue, apparently as a "gotcha".

Over on DoubleX, KJ Dell'Antonia makes the good feminist point. With the HPV vaccines, conservatives raise a fuss that removing the risk of STD's will make girls more sexually promiscuous. In the circumcision debate, silence on the promiscuity front.

There's a double standard. What does that prove with respect to justifying infant male circumcision? Because a group of people make a stupid, sexist assertion about one point, their silence on another human sexuality topic confers credibility to the intervention? Focusing on this gives the unserious nutters too much credit.

Anyway, it's far more logical to highlight the double standard inherent in having anti-FGM laws in America that prohibit parents and doctors from altering the genitals of female minors for any reason other than medical need, including the cultural and religious claims of the parents, while leaving open the option for parents to circumcise healthy male minors for any reason. There are important caveats to raise in the differences in male and female genital cutting, but the ethical question involves basic human rights. When considering that less invasive cutting is prohibited on female minors compared to what is permitted (and potentially encouraged) on male minors, the difference is in degree, not in kind, and can't be swept away with the same tired deference to potential benefits. But that would involve addressing the issues rather than side-stepping them to score cheap rhetorical points and declaring victory.

August 24, 2009

Because... HIV!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

July 13, 2009

Fear for Sale

This entry by Patri Friedman is old in Internet terms (i.e. one whole month), but it's timeless and interesting. I can't do it justice without posting it all, I think, so here it is:

Among my many contrarian beliefs, I don't believe in pandemics. Not that they haven't happened, or that they can't happen, but that incipient pandemics reported by the CDC, WHO, and the media are fearmongering and blown way out of proportion. SARS, bird flu, and swine flu are the most recent examples.

Here is the problem. The CDC and WHO exist to fight global health issues. Having them report on the dangers of pandemics is like asking the American Association of Sleep Doctors whether people are getting enough sleep. They have a huge incentive to find danger. Combined with media sensationalism, the result is a lot of bullshit.

In typical govt agency fashion, the approach is sneakily win-win. If the pandemic materializes, it is blamed on nature and inadequate funding - the agencies did the best they could. Surely you can't short them in the budget now! If it doesn't materialize, it was due to their noble efforts, and they deserve at least cost of living raises. Either way, more supposed threats gives more opportunities for wins.

Its too bad that prediction markets don't seem to work in practice (only a narrow set of topics produces the trader interest required for liquidity and good estimates), because conditional policy markets ("how many people will die of the flu if the CDC budget is $XXM next year?") are a theoretically great answer. Funding these agencies like traditional nonprofits, accountable to their donors, rather than via politicians spending other people's money, would be a step in the right direction.

Every word is relevant to the way WHO, CDC, and the media treat circumcision and HIV. If we don't circumcise every male from birth, 25 trillion people will become infected with HIV next year. Because it's the foreskin, not unsafe sex, that leads to HIV transmission. No matter what, though, know that the data will tell the story the organizations want to tell.

I find the prediction market idea fascinating, too. In this context, I'd take a large short position that HIV rates will decrease as predicted among the newly circumcised men and children in Africa.

May 28, 2009

Where Does the Comparison Fail? Part Two

I compared infant male circumcision to tattooing a child based on a recent example from California. My original analysis translates to this story:

A Floyd County man has been charged with child cruelty after authorities say he tattooed his 3-year-old son.

Floyd County Police Sgt. Teri Davis said Eugene Ashley, 24, tattooed the back of his son’s right shoulder with “DB,” which stands for “Daddy’s Boy,” sometime this spring. The man told police he was intoxicated at the time, Davis said.
...

The children remain with their mother; Eugene Ashley was arrested May 21 and faces charges of child cruelty and tattooing a person younger than 18 years old, the latter being a misdemeanor, Davis said.

Like father, like son. Right? Or is there some limit to parental consent and imposition? Again, both a tattoo and a circumcision are a permanent mark on the child's body without the child's consent. There is justifiably a law against tattooing, but there are more dangerous risks - bleeding, infection, amputation, death - involved in circumcision, an unnecessary surgical procedure. This is a double standard with no justifiable defense.

As I wrote in my initial entry:

None of these possible exemptions satisfies the primary ethical flaw in either violation. The act is forced upon the child without his consent. Necessity requires an acceptance of limited proxy parental consent for infant male circumcision that does not exist for tattooing because the probability of a medical need for circumcision is not equal to zero. But when the surgery is unnecessary to the child's health, circumcision is the same violation, a permanent change to the child's body without his consent. The disparity in protecting the rights of children is obvious and inexcusable.

For a few opinions on this story, read through the mind-numbing comments at Momania, Theresa Walsh Giarrusso's blog hosted at the Atlanta Journal-Constitution. Is it informed to have an opinion no deeper than "what we do is good, what we don't do is bad"?

May 18, 2009

Where does the comparison fail?

Consider:

Police say 26-year-old Enrique Gonzalez held the boy while another gang member tattooed his right hip. ...

Gonzalez has been booked into the Fresno County Jail on suspicion of child abuse, mayhem, false imprisonment and a host of crimes with gang enhancements.

The (alleged) actions of the father are wrong, a conclusion virtually everyone will agree upon. Society is correct in prosecuting this as child abuse.

Yet, society's laws also allege that parents have an unquestionable right to circumcise their (male) children - a permanent change to the child's body - based only on a parental conclusion that some social benefit might exist for the child. We are not to judge those family decisions (on boys only, remember) made for subjective reasons.

Joel Stein satirized this mentality in a recent issue of Time when he wrote that "circumcision is something the U.S. does and Europe doesn't and is therefore awesome." Stein used this as a tongue-in-cheek way to introduce his skepticism on the issue. It wasn't funny because he recognized the violation of circumcision and still forced it on his son, but the attempt at humor was obvious. Someone like Dr. Edgar Schoen uses this same faux-patriotism in his books as an excuse to continue parental choice on infant male circumcision for social reasons without noticing the absurdity of this forced inclusion. The law sides with Schoen's stupidity on infant male¹ circumcision, which raises the question: How is tattooing a child any different than forcing unnecessary surgery on him?

The law permits parents to have no reason, but "like father, like son" is among the non-medical excuses most commonly provided. The medical community pushes this and few question it. Presumably the child in the news story above would've experienced greater acceptance and status among his father's peer group² by having the tattoo. Why is one ethical framework applicable in one scenario and inapplicable in an analogous scenario, if not to cherry-pick for outcome? Because one violation is uncommon and the other is practiced more than one million times each year? Because one leaves a mark accepted by most while the other leaves a mark shunned by most? I'm curious to know because the answer isn't logical.

None of these possible exemptions satisfies the primary ethical flaw in either violation. The act is forced upon the child without his consent. Necessity requires an acceptance of limited proxy parental consent for infant male circumcision that does not exist for tattooing because the probability of a medical need for circumcision is not equal to zero. But when the surgery is unnecessary to the child's health, circumcision is the same violation, a permanent change to the child's body without his consent. The disparity in protecting the rights of children is obvious and inexcusable.

¹ The law explicitly forbids this nonsense for female genital cutting, which is informative and worth exploring until the law changes. But it is beyond the scope necessary for this blog entry.

² It's also possible to make a reasonable comparison here to the locker room theory used to justify circumcising male children.

May 15, 2009

Families Consist of Individuals

Via KipEsquire's Twitter feed, here's an interesting case about the power of the government to overrule medical decisions made by parental proxy.

A Minnesota judge has ruled a 13-year-old boy with Hodgkin's lymphoma, a highly treatable form of cancer, must seek medical treatment over his parents' objections.

In a 58-page ruling Friday, Brown County District Judge John Rodenberg found that Daniel Hauser of Sleepy Eye has been "medically neglected" and is in need of child protection services. Rodenberg said Daniel will stay in the custody of his parents, but Colleen and Anthony Hauser have until May 19 to get an updated chest X-ray for their son and select an oncologist.

Going only this far into the story, I'm inclined to believe that this is wrong because other reports I've read state that the boy understands his condition. Thirteen is not objectively too young for the child to consent or refuse. There must be a sufficient standard (the details are difficult and beyond the scope of this entry) to judge the child's competence in the matter, but if the child passes that, I see no reason to interfere.

Rodenberg wrote that Daniel has only a "rudimentary understanding at best of the risks and benefits of chemotherapy. ... he does not believe he is ill currently. The fact is that he is very ill currently." Because of that and other evidence in the case, Rodenberg ruled there is a "compelling state interest sufficient to override the minor's genuine opposition."

Parents act irresponsibly if their child is incapable of deciding and they choose treatment (nutritional supplements and other alternative treatments) with no scientific basis instead of treatment (chemotherapy) with a high success rate. There are no perfect decisions in something as complex as cancer. Still, some level of objective comparison is possible, and success rates show this isn't close. Doctors say he has a 5 percent chance of survival without chemotherapy and up to 90 percent with it.

A court-appointed attorney for Daniel, Philip Elbert, called the decision unfortunate.

"I feel it's a blow to families," he said Friday. "It marginalizes the decisions that parents face every day in regard to their children's medical care. It really affirms the role that big government is better at making our decisions for us."

Government has a role to play when people make decisions for another person. Pick a scenario where that qualifier isn't involved and I will defend an individual's right to make subjective, possibly fatal decisions for himself. But within that scenario, which applies to medical (and non-medical) decisions parents make for children, the government's role is legitimate. It must protect the child from neglect and abuse, regardless of parental intention.

This case is similar to the case of Abraham Cherrix. My entry is here.

April 13, 2009

I should have thought of this long ago.

One of the common defenses of infant male circumcision is that it's the parents' decision and that they make many decisions that may or may not be the best decision. The argument is that the State is no more qualified to make those decisions than the child's parents. I disagree with this, as I've explained before. (One example here.) And it's obviously ridiculous because we've already legislated against parental decision-making for the genitals of their daughters, prohibiting the same excuses we permit for the genitals of sons. There is no valid line of thought that supports that legal distinction.

I'd already reached that conclusion, of course. But I consistently missed a fallacious approach to the argument. If parents have "rights", a proxy power granted only to the genitals of their sons can't be legitimately referred to as a right unless we concede that the state is infringing upon their right to cut their daughters. This should be obvious, and it always has been to me. However, the argument based on rights generally leads to a statement that among the many decisions parents make for their children include such decisions as where to educate them, whether or not their friends are acceptable, and what to feed them. Those are all valid parental decisions.

Those are an unintentional distraction from the real question. The (male) circumcision decision for parents of a healthy (male) child is whether to allow their (male) child to keep his normal anatomy or not. The analogous decision is not whether to send their (male) child to school X or school Y. The analogous decision is whether to send their (male) child to school or not. The analogous decision is whether to allow their (male) child to have friends or not. The analogous decision is whether to feed their (male) child or not.

In every one of those examples, we immediately recognize the legitimacy of state intervention to prohibit objectively reckless decisions. (The anarchists don't, but that's a different blog entry.) The decision to circumcise a healthy male child is no different when properly analyzed.

Even when the claim is medical benefits, those benefits are merely potential benefits for risks that are universally low to begin with for normal males. The remaining non-medical reasons people offer simply cannot withstand any rational consideration of the truth that prophylactic circumcision is an invasive surgical procedure forced upon a healthy individual, with all the inherent risk of complications and without any direct medical need. Again, we fully understand this basic truth for the normal, healthy genitals of female minors. The notion that parents possess a right to proxy consent distinguished only by the gender of the child is indefensible.

April 12, 2009

If You Can't Beat Them, Resort to Name-Calling?

There's a new meme popular among advocates of routine infant circumcision referring to those who oppose routine infant circumcision as "foreskin fetishists". It's not a surprising strategy because it's the type of tactic deployed when one is on the wrong side of logic and facts. It's been deployed against me, and I've seen it deployed as a general tactic. It's unwise to the point of being odd, since it's so easy to dismiss with a simple observation. But it's clear those who use it do so because they realize that most people believe what they're told if it fits their opinions, not what fits with reality. Smear your opponent and some will buy it.

So, the claim itself. I support the right for each male to choose for himself. If he chooses circumcision for any reason, that's his right. If he chooses against circumcision for any reason, that's his right. My only concern is that each healthy child be left his choice for when he can consent or refuse.

Circumcision advocates believe that parents should choose. They are wrong, for the many logical reasons I continue to write about. This isn't the place to rehash most of those directly. However, there is one that is relevant. I'll point to a claim by Professor Brian Morris, linked in the entry I posted yesterday.

Getting circumcised will result in:
...

• A penis that is regarded by most as being more attractive.

And what about Dr. Edgar Schoen?

Women's Preference, Sexual Activity, Psych Effect:

Sexual function is not adversely effected by NC. On the contrary, published evidence shows that circumcised men have a wider variety of sexual activity, and women prefer circumcised men, mainly because of better genital hygiene.

I can find any number of further examples, but the point should be clear. If there are fetishists, which side contains the fetishists? Is it those who advocate for each male to choose for himself for his reasons or those who believe that parents may impose unnecessary surgery on their son's genitals because they believe his future partner(s) will find his circumcised penis more sexually appealing?

Anyone who tosses this meme around is engaging in propaganda.

**********

For an example, consider this entry from Dr. Amy Tuteur. She labels herself "The Skeptical OB", but it will be clear that she is hardly skeptical in any meaningful way on circumcision. She opens:

A visitor from outer space might be forgiven for concluding that the most important part of the human body is the foreskin. It is, after all, the only part of the body that has multiple organizations devoted to its preservation in the natural state. The visitor might get the impression that the choice of circumcision is a fateful choice with profound implications for the rest of life.

It is the only part of the body that has multiple organizations devoted to its preservation in the natural state because it is the only body part we regularly remove from non-consenting individuals in its natural (i.e. healthy) state.

... Foreskin fetishists also employ inflammatory language to express their judgmentalism. Circumcision is “mutilation” and parents who choose to circumcise their sons are “mutilators”.

Does fetishist qualify as "inflammatory language"?

The foreskin fetishists are so obsessed with the foreskin that they actually dare to advance the misogynistic claim that male circumcision is analogous to female genital mutilation, in other words, that the foreskin is the analogue of the clitoris. The male analogue of clitoridectomy is is amputation of the penis. Comparing circumcision to clitoridectomy is like comparing ear piercing to having your ears cut off.

My claim is that unnecessary genital cutting on a healthy, non-consenting individual is wrong. Gender makes no difference to that principle. That is a different, and more fundamental, claim than what Dr. Tuteur puts forth for people who state (accurately) that female and male genital cutting are comparable.

She adds to this in the comments:

The comparison is essentially misogynistic. FMG exists specifically to prevent female sexual activity by permanently removing the possibility of sexual enjoyment. Male circumcision is performed for religious reasons or for medical benefits. It has nothing to do with sexual satisfaction, and is certainly not meant to interfere in any way with male sexual satisfaction.

Every claim in that comment is incorrect. There is no misogyny in stating that males and females possess equal human rights. FGM exists for many reasons and in different forms, not all of them intended to permanently remove the possibility of sexual enjoyment. (They may still do that, and probably do in most cases. But that's obvious because parental intent does not guarantee good outcomes, another point not specific to the gender of the recipient.) Male circumcision is also performed so that parents don't have to learn how to care for a normal penis or so that the son will look like the father or so the mean kids won't pick on him in the locker room or because his parents think women won't sleep with him if he has his foreskin. The latter point is clearly about sexual satisfaction. And whether or not it is meant to interfere is subordinate to the truth that it interferes with male sexual satisfaction. That interference could be positive, negative, or neutral, but only the male himself can make the relevant determination to that subjective question.

Anti-circ activists like to claim that there only risks and no benefits to circumcision, but that is not true.

Dr. Tuteur links to zero sources making this claim. I don't doubt that some people are making that claim. People on both sides make ridiculous claims. Still, if one wants to make a sweeping claim, defend it with evidence.

Yesterday, I wrote that "[t]he reduction in UTI risk is likely real. The reduction in HIV-infection risk is likely real, at least in the short-term. And so on. I accept this." This is not complicated, but as I added after that statement, it is not enough to dismiss the fact that the child is healthy at the time of the surgery. That makes the ethical evaluation the primary focus. Non-therapeutic circumcision fails this test. Yet Dr. Tuteur seems uninterested in anything more than potential benefits as an excuse to permit parents to make the decision.

She defends this opinion in the comments:

Parents have the right to consent to ANY surgery, brain surgery, heart surgery, so consenting to removal of the foreskin is hardly a big deal. Moreover parents have the right to consent to piercing, removal of birth marks and other forms of body modification.

Do parents have the right to consent to non-therapeutic brain or heart surgery for their healthy children? A heart stent for a 2-year-old because he might have problems at 50?

The core evaluation is very simple. If the child is healthy, no surgery is indicated or justifiable. Chasing benefits for children is an illogical path that can be pursued to other irrational avenues and on both genders. It has no place in the proxy decision-making of parents for the genitals of their male children, as we already understand clearly for female children.

April 11, 2009

Quick Comment on Two Posts

I've written two posts responding to a series of statements and entries a blogger posted on infant circumcision. They're extensive, so I expect only the truly interested will read them. However, I'd like to point out an interesting and useful section from each. From the first entry, in response to a claim by Professor Brian Morris on the cost of circumcision for infants and adults:

Speaking strictly from a finance perspective, advocating for infant circumcision is the more expensive approach. His analysis is that the cost is 10 times 0.1 for his preference and 0.1 times 10 for his worst case. The present value of $1 spent over many years in the future is less than the $1 spent today. Professor Morris prefers the more expensive option.

From the second entry, apropo to this recent tweet directed to me, this:

Infant circumcision is a surgical procedure performed without medical need because it offers potential health benefits. The latter defense is what proponents obsess on, as the author does here. But just to prove that the author's last claim is ad hominem deployed to prop up her indefensible case, there are potential advantages to being circumcised as an infant. The reduction in UTI risk is likely real. The reduction in HIV-infection risk is likely real, at least in the short-term. And so on. I accept this.

But so what? That gives no validity to prophylactic infant male circumcision. There are better, more effective, less invasive ways to achieve every single benefit or to treat the maladies in the unlikely instances where they occur. The objective health is what matters for proxy consent for a child. Is the intervention indicated and necessary? Infant circumcision fails this core test. Moving forward is unethical because objective reality trumps the subjective chase for justifications.

As I responded to that tweet, I don't refute the scientific research. I reject the flawed (i.e. unethical) application of that research. There is a difference.

It's worth noting, too, that I can accept the scientific research because my position remains strong regardless. The position that relies on the scientific research without ethics or core facts pertinent to each individual case falls apart if it acknowledges anything beyond its talking points.

This does not mean that I think the studies looking for potential benefits are sound and will withstand the scrutiny of time and further research. I suspect many of them won't. The history of infant circumcision and the search for potential benefits demonstrates the belief in stagnant arguments for the procedure to be a silly proposition to defend with any certainty. Still, I can accept the findings as present scientific consensus. But I will continue to probe those potential flaws, as anyone who cares about science and furthering knowledge should. We don't stop just because we find the answer we want.

Only One Fact Is True for the Individual Child - Still

Following on my last entry, Lauren at Can You Be A Part of My Life continues her series on circumcision with information from her next source, a list at Justmommies.com titled "Common lies about circumcision". I'll get to that in a moment. First, this from Lauren's second entry, "Follow Up Facts and Statements":

It isn't necessary for a Harvard bullshit artist to come and spout his manipulative opinions either or any other such nonsense. And furthermore there are serious HUMAN RIGHTS VIOLATIONS happening right now in the world toward women, mostly in MUSLIM countries right at this moment. Girls being "honor killed" and women being flogged or hung because they spoke to a man outside of their family or because they were raped by thugs. So please spare me the human rights cockamame argument about less than an inch of skin that is done to increase the health and well-being of little boys as well as grown men.

An action doesn't have to be "serious" to be a human rights violation. Major violations occur every day. They should not be overlooked. Killing a woman (or a man) is worse than cutting the genitals of a man (or a woman). This does not negate the argument that male genital cutting is a human rights violation. Unnecessary genital cutting on a healthy, non-consenting individual is wrong.

We can look at gender, but that is analyzing degrees of reality, not separating the two actions from each other. Anti-FGM laws rightly dismiss any reason for cutting a female minor other than immediate medical need. No consideration of religion matters. No consideration of extent of cutting matters. No consideration of potential benefits, either medically or socially, matters. Only the child's immediate, objective health needs inform the decision.

How is that logic exclusive to females? Males are equally human beings, with equal human rights. The undeniable fact that great atrocities occur against women in other parts of the world does not excuse violations in the Western world. Nor does calling infant male circumcision a violation suggest an indifference to or acceptance of genital mutilation (and other atrocities) committed against women. Again, unnecessary genital cutting on a healthy, non-consenting individual is wrong. How we punish each depends on the circumstances of the actual cutting on the individual and why, but gender is not the proper identifier for what is and is not harm.

**********

Like her last entry, Lauren provides a list from her source without additional commentary. She lists the first four items. The justmommies.com list of "common lies" icludes twenty-six items. I will address the statements that need comment or rebuttal.

2) No organization in the world recommends circumcision:

... Both the World Health Organization (WHO) and the United Nations (UNAIDS) have recommended circumcision as a preventative measure against AIDS.

The studies WHO and UNAIDS rely on involved adult volunteers. Children are neither. Nor are infants sexually active, in need of protection against STDs. The ethical issue can not be dismissed simply by assuming that the findings from Africa, where the HIV epidemic is different, should be transferred to male minors in Western nations.

Remember, six days after the findings, UNAIDS stated that circumcision plans should start with infants. If there's an epidemic that warrants circumcision as an action plan, it is irrational to start with those males who will not be sexually active for more than a decade. I won't respect their judgment on ethical issues, which is what prophylactic genital cutting is.

4) Circumcision is a human rights violation:

Not true. I agree there are some people that think that circumcision should be a human rights violation and they have every right to feel that way. Still, that doesn't make it a reality. We have accepted organizations that deal with these issues and decide- based on many factors- which activities are acceptable and which violate basic human rights. These organizations have agreed that circumcision IS NOT a human rights violations because of it's a very safe procedure and it carries some medical benefits. This myth usually goes hand in hand with a comparison of male circumcision and Female Genital Mutilation (FGM). However, the two practices are completely different in every single aspect: physical, psychological, emotional, social and religious. They're not comparable in the slightest, but since they're both done is the same general area, and because FGM is a degrading practice and an accepted human rights violation, anti-circumcision activists usually use it to try to put circumcision in a more negative light. Sadly, it does the opposite. By comparing something as traumatic, damaging, dangerous and degrading as FGM with a simple, safe and beneficial procedure demeans the impact of FGM. It's a poor way of treating the women that have been victims of FGM and a way to demean their pain.
Finally, Amnesty International has directly declined to accept male circumcision as a human rights violation 3 times.

I've already addressed this, and the justmommies approach should convince no one otherwise.

To one specific claim, I've long thought that people who reject the simple claim that unnecessary genital cutting on a healty, non-consenting individual has no valid gender distinction are determined to believe that my argument intends to diminish the violation of FGM rather than change society's mistaken beliefs about male genital cutting. I have been very clear that FGM is mostly worse, and to a large extent. That does not change the core point. Murder is the ultimate violation, but that does not mean that a punch to the face is therefore valid because it is a lesser violation. The issue is the act, not the gender.

For a slight deviation to continue this point, in her entry Lauren responds to a comment with this:

@Rhonda- yes you did what you felt was best and right and that is the point. KUDOS! and hugs.

The point is is what is done, not why. They are separate. A well-intentioned action can be flawed. This gets to the core that the right belongs to the individual child, not to the parents to decide based on their preferences. Very often those preferences are objectively indefensible.

8) Circumcision affects sexuality

No reliable study has proven that circumcision has any effect on sensitivity and overall sexual function. ...

Circumcision clearly affects sexuality. That is not open to dispute because it changes the structure of the penis. How that change is evaluated may be positive, negative, or neutral. Only the person losing a portion of his healhty genitals is may make the unnecessary decision based on his conclusion on whether the change is positive, negative, or neutral. His evaluation may not match that of his parents.

10) Informed parents will choose not to circumcise

Actually, since information exists to support arguments from both sides, informed parents can make either choice.

The fact that there are two sides demonstrates that parents make a subjective decision. When that decision is unnecessary, as it is with almost every child circumcision, informed has no meaning. The parents act without input from the child on an irreversible - and, again, usually unnecessary - surgery. That is different than what #10 attempts to reject.

The shorter version: the circumcision decision for a child should be informed only by whether or not it is necessary.

12) Most babies are circumcised without pain relief-

Lies, lies. Unless you're stuck living in the 70s.
But for the rest of us who accept and embrace the new millenium, the vast majority of circumcisions are now performed with pain relief.

I was circumcised in the '70s, probably without pain relief. Was that a violation of my rights? And is it not a violation for the boys not in the "vast majority" who are given pain relief?

Proper pain relief does not make the surgery defensible. Behaving humanely in an indefensible action changes nothing.

13) Moms who choose not to circumcise are protecting their sons

Nice emotional outburst, completely in character of intactivism who love to use guilt and fear to spread their message, but completely false.
Protection is highly subjective and according to what we believe, our definition of "protecting" will be different. Sure they're "protecting" their children from initial pain and from the tiny risks of circumcision. But parents who choose to circumcise will tell you they're protecting their children from penile cancer, phimosis, balanitis and all that list we now know by heart.
It's a common anti-circ tactic- language twisting.

First, it's interesting that throughout the list the author rejects the simplifications used by those against infant circumcision, yet it's somehow reasonable to engage in the same behavior against those people.

To the issue in #13, saying that you're protecting your son from penile cancer, phimosis, etc. is the same tactic. The correct analysis in this silly use of protect is that not circumcising a healthy child protects him from the risk of complications. Without need, the risks inherent in the surgery are all that are immediate.

14) How can it be cleaner to have urine and feces directly up against an open wound?

Ok, first of all, the "open wound" lasts for like two days. ...

If it is "like two days", that's two days longer than an intact penis is an open wound.

16- Circumcision isn't "just a snip"

Actually, that's exactly what it is. You see, a "snip" is "to cut with a small, quick stroke, or a succession of such strokes, with scissors or the like." and "a small cut made by snipping". Both describing circumcision perfectly.
Why the common lie saying that it isn't a snip? Because intactivists love to say that the adult foreskin measures 3 x 5 inches. But we're not talking about adult foreskins, are we? At the moment the foreskin is removed, it's a small piece of skin, therefore, regardless of how big it becomes, at that moment, it's a "snip". So infant circumcision is just a snip. Adult circumcision is a little more complicated.

The author rebuts on semantics while ignoring the word that is the center of the argument. "Just a snip", not "just a snip". One word is an objective claim, a fact the author pointlessly focuses on. The other word is a subjective evaluation. Who is to decide what qualifies as just anything?

I could use a reference to boys who suffer serious complications and ask if they consider it just a snip. That's valid, but the more common outcome is more useful here. Does the male who receives the expected results from the surgery think it's just a snip? Would he value the subjective benefits of having his normal body more than the subjective value of the potential benefits his parents forced upon him? Words have meaning.

Like Lauren's use of "about less than an inch" in the excerpt above, the author thinks we should focus on what foreskin is removed rather than what will be if we don't remove the foreskin. But what will be there matters. Like in economics, what is unseen must still factor in the process. Removing X will have a result as an adult. Removing X - Y will have a different result as an adult. Removing X + Y will have a different result as an adult. X - Y can lead to adhesions. X + Y can lead to painful adult erections. It is impossible to know. That is the key. We can't pretend that what we want to be will be what is if we ignore inconvenient facts.

17) Doctors who perform circumcision violate the AMA's Code of Ethics:
...

A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.

I'm going to break this excerpt apart to deal with two principles separately. With this one, surgically altering a healthy child who will most likely grow into a healthy adult is a violation of that child's human dignity and rights. The child is the patient. What he needs or doesn't need is the only factor in competent medical care. If it is wrong to cut a healthy female, it is wrong to cut a healthy male.

A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
...

VIII. And seeing as all medical organization agree that the "best interests" of the patient in the cases of infant circumcision are to be determined by the parents, a doctor abiding by the wish to circumcise doesn't violate this principle.

Responsibility to the patient is paramount, but somehow bowing to the wishes of the parents to surgically alter their healthy sons, even for non-"medical" cultural and religious reasons, doesn't violate this because medical organizations agree that it's okay? No. The analysis must focus on objective facts, not what people simply agree to believe.

Using the author's convoluted rationale, female genital cutting was acceptable in Victorian England and America in the 1800s because doctors agreed that it was beneficial. Or today, countries that cut females could use the same rationale because of what they collectively believe. The author's requirement that a majority consensus is all that's necessary is unbounded by principles, just socially approved behavior. How do we decide whether the medical organization is correct? Consensus means nothing by itself.

19) Considering male circumcision acceptable and FGM (Female Genital Mutilation) wrong is a "double standard".

First of all, what IS "double standard"? Here are some definitions.

American Heritage Dictionary - Cite This Source - Share This

double standard
n. A set of principles permitting greater opportunity or liberty to one than to another, especially the granting of greater sexual freedom to men than to women.
...

Now, if we STRICTLY adhere to what a "double standard" is by these definitions, then we can consider underage prohibition to drink, smoke or vote, the Olympics, non-smoking rules, etc, "double standards" and therefore unacceptable.

This means, obviously, that there are certain acceptable double standards. Furthermore, it means that in order to consider something an actual double standard, there are other considerations besides the treatment received by the two groups. So basically, to speak of an actual double standard, all things being equal, one group is being treated differently.

Men and women ARE different. I don't see anyone claiming that we should remove the gender categories from the Olympics because it's a "double standard". Why not let men and women compete against each other if we're SO "equal"? The answer is because we're not absolutely equal. It's a physical fact that men are generally stronger and faster than women. It would actually be unfair to have women compete against men as the former have a physical advantage.

And if we're saying that men and women are physically different, nowhere is this difference more pronounced than in the genitals. Male and female genitals are different. Therefore, the consequences of removing the foreskin cannot be compared with those of removing/altering female genitalia. And because of this, differentiating between the two IS NOT a double standard.

A female minor may not be cut even if the culture she is born into believes that cut female genitals are preferable, yet male minors may be cut for this cultural reason. How is that not included in "a set of principles permitting greater opportunity or liberty to one than to another"? Females are granted the liberty to decide what to do - or to not do - with their normal bodies that is not granted to males. That is a double standard.

The remaining arguments are unconvincing. To compare forced genital cutting to voluntary involvement in something like the Olympics is ridiculous. We do not agree that male and female genitals are different in the way they're being discussed. There is not a set of principles that apply to the vagina and another set of principles that apply to the penis. The set of principles apply to human beings. Human beings have genitals. Those genitals have reproductive, sexual, and excretory functions. Consideration of male versus female in how genitals should be protected is an incorrect deviation from logic. The individual human beings matter exclusively.

Yes, we make distinctions for smoking, drinking, and voting. However, those distinctions apply to everyone. The difference is that everyone has the the opportunity to be included in that group. Everyone will reach the minimum age for each (in most cases). Not everyone will meet the distinction the author demands for protection from unnecessary genital cutting on a healthy, non-consenting individual. There is no point in my life when I will become a female, reaching a basic level of protection. I was unprotected in childhood, and my genitals were altered. Females are protected from birth from having done to their genitals what was done to mine. That is a double standard.

21) Adult circumcision is easier and safer than neonatal circumcision

Nothing could be farther from reality.

And most males left intact will never need or choose circumcision. The fact that something can be done easier in childhood is not a justification that it should be done. It changes the decision from "Should it be done?" to "Is it difficult?". This is the "he won't remember it" defense. What else may parents do to their children because their children won't remember it? If a parent punches the child, the child will not remember it. And it will do less damage to the child than circumcision. But we know it's wrong to punch a child in the face. "Is it difficult" to recover from is not part of the equation.

23) Circumcision is a "cosmetic" procedure

No. Circumcision is a MEDICAL procedure, with proven HEALTH benefits acknowledged and admitted by every single medical organization in the world. Therefore, it's not just "cosmetic", it's prophylactic.

Why the intactivists' insistence that it's just "cosmetic"? Very simple, really. By saying that parents are doing something "cosmetic" to their children it makes the choice seem shallow, selfish and useless. By even admitting that there's one advantage to being circumcised, they would be giving some validity to circumcision and there's no way a self-respecting intactivist will ever agree to any validity. Therefore, they spread the lie that it's just "cosmetic".

Infant circumcision is a surgical procedure performed without medical need because it offers potential health benefits. The latter defense is what proponents obsess on, as the author does here. But just to prove that the author's last claim is ad hominem deployed to prop up her indefensible case, there are potential advantages to being circumcised as an infant. The reduction in UTI risk is likely real. The reduction in HIV-infection risk is likely real, at least in the short-term. And so on. I accept this.

But so what? That gives no validity to prophylactic infant male circumcision. There are better, more effective, less invasive ways to achieve every single benefit or to treat the maladies in the unlikely instances where they occur. The objective health is what matters for proxy consent for a child. Is the intervention indicated and necessary? Infant circumcision fails this core test. Moving forward is unethical because objective reality trumps the subjective chase for justifications.

However, if the author wishes to imply that the potential benefits dismiss the cosmetic nature of the surgery as a reason why some parents circumcise their sons, she is mistaken. There are parents who circumcise for cosmetic reasons. They find the foreskin "icky" or dangerous or bothersome. The fathers and mothers prefer circumcised penises sexually (for different reasons, obviously). They push this preference on their sons because they assume that the child's future partners will share their opinion on the aesthetic value of a circumcised penis and thank them. Sometimes, they also assume that the child will agree, although they assume that the opinion of his partners will determine his opinion. For this segment of parents, circumcision is a cosmetic decision. We allow child circumcision for this subjective reason because we mistakenly believe that this determination can be defended as the parents making a decision in the child's best interests. It is not because parents are not psychic. They can't know what he will prefer, or whether he would willingly enter a sexual relationship with someone shallow enough to expect his body to be changed to meer her (or his) expectations.

It is appalling that parents consider their opinions relevant on the subjective question of unnecessary genital cutting. It is obscene that they consider them superior to the child's opinions, both real and potential, for these irrational excuses. That is a shameful mark against our society, and should be recognized as such by the law.

Only One Fact Is True for the Individual Child

In an entry titled "The Facts As Promised", Lauren at Can You Be A Part of My Life fails to consider the context of her selected (and occasionally incorrect) facts about infant circumcision. I expected little going in because she opened with her attributions. Among her three sources were the websites of Professor Brian Morris and Dr. Edgar Schoen. It would be difficult to find a greater propagandist than either of those two.

Throw that truth out, though. Where they are correct with statistics, they ignore the most important fact present in almost every case where they advocate infant male circumcision, which Lauren readily ignores along with them: the child is normal and healthy. No surgery is indicated. There is no need to weigh against the inevitable risks. That is the only proper evidence-based analysis. One need not reject any of the statistics claimed to understand that the individual does not require circumcision. Circumcision by parental proxy is therefore unjustifiable.

But the claims merit a response. Here is an excerpt from the first paragraph of substance on circumcision in Lauren's entry:

... And it is MUCH harder to keep this area clean in infant babies for various reason and therefore leads to: a higher risk of death in the first year of life (from complications of urinary tract infections: viz. kidney failure, meningitis and infection of bone marrow).

WebMD, a site that generally endorses unnecessary infant circumcision, states this about the normal infant foreskin, with emphasis in the original:

Do not force the foreskin back over the tip of the penis. At first, a baby's foreskin may be difficult to pull back over the tip of the penis. After the first few years of life (though it may take somewhat longer), the foreskin will gradually become more retractable. By the time a boy is age 3, his foreskin is usually fully retractable. Up to this time, wash the outside of the penis with soap and water. Pushing your son's foreskin back too early can cause scar tissue formation and damage.

Is washing the intact penis that MUCH harder to keep clean than the circumcised penis? Considering the process is identical, it's clearly not MUCH harder. Pretending otherwise is misinformation. It is also worth remembering that circumcision creates an open wound that must be cared for properly to avoid infection and readhesion. This makes care for the circumcised penis more complicated for parents than properly caring for the normal penis.

Here I'd like to add a special caveat. If you don't wish to care for normal, healthy children, don't reproduce. Otherwise, the proper care of your normal, healthy children is an obligation, not a chore to be discarded in reverence to fear and mistaken beliefs.

For the the remainder of this entry, I'll take the issues point-by-point. However, I want to make it clear that from this point forward, I'm challenging the claims of Professor Brian Morris. The bulk of Lauren's entry involves only a copy-and-paste from Morris' site. Lauren (wisely) provided some editorial input, omitting several absurdly irrelevant claims proffered by Morris. Of course, those should be considered to fully understand his judgment in pushing the other claims over the objective reality of health for most infant males. "A penis that is regarded by most as being more attractive" is not an indication of medical necessity. It's a sign of an ability to think only collectively, to not understand that all tastes and preferences are subjective and individual. That is flawed because it ignores ethics and human rights.

So, addressing Professor Morris' claims. (Link is here: http://www.circinfo.net/summary.html) Under the section titled "The benefits are clear" from Lauren's entry, this list from Morris titled "Getting circumcised will result in":

  • Improved hygiene.

This is misleading, at best. See my comments above on this.

  • Much lower risk of urinary tract infections.

The risk is lower, by a factor of approximately 10. However, the risk is already very low. More on this in a moment. (Note: The risk for girls is also approximately 3 times higher than it is for intact boys. We treat UTIs in infant girls if/when they appear.)

  • Much lower chance of acquiring AIDS heterosexually.

Condoms and monogamy or condoms, monogamy, and circumcision. Those are the two choices. Circumcision is superfluous. Unprotected sex with HIV-infected partners will lead to infection. Circumcision has not helped me avoid HIV infection because I do not behave irresponsibly. Had my parents used this excuse, it would've been misguided. Parents are not Nostradamus.

Notice, too, how easily this omits the fact that the studies were performed on adult volunteers, not infants. Surgery is different technically and ethically for the two patient groups. The infant foreskin must be forcibly retracted. Infants aren't sexaully active.

  • Virtually complete elimination of the risk of invasive penile cancer.

The risk of penile cancer is small, regardless of foreskin status. From the 1999 AAP statement on infant circumcision, the risk of penile cancer varies little among Western nations. It is generally around 1 per 100,000 males. Other risk factors appear to be more significant. The consensus seems to be that, circumcised or not, healthy, responsible living is the best way to protect against such illnesses.

For context, there were 1,250 new cases of penile cancer in America in 2008 and 290 deaths. There were an estimated 1,990 cases of invasive breast cancer in American men in 2008, including 450 deaths. Time to panic and remove infant male breast tissue? The logic would be the same.

  • More favourable hygiene for the man’s sexual partner.

This can be read as either a claim that women prefer a circumcised penis because it is cleaner or that it improves female hygiene. I've already dismissed the former claim, and Lauren correctly points out the absurdity of suggesting that adult males are incapable of cleaning their foreskins. The latter claim would tie in to the next bullet point.

  • Much lower risk of cervical cancer and Chlamydia (and thus infertility and other problems) in the female sexual partner.

The ethical questions aside, there is a vaccine for HPV. That aside, as it relates to the foreskin, personal responsibility among the sexual pair matters: "In men with low-risk sexual behaviour and monogamous female partners, circumcision makes no difference to the risk of cervical cancer." It is flawed to assume at birth that the male will be promiscuous. It is also flawed to assume that it's ethical to surgically alter one person to protect his potential sexual partners. For example, what if he is gay?

  • More favorable sexual function and no reduction in sensation during arousal or in the sensitivity of the flaccid penis.

Circumcision clearly alters sexual intercourse. Whether or not that is "more favorable" - a subjective evaluation - can only legitimately be determined by the individual himself. The foreskin contains thousands of nerve endings. Again, removing those alters sexual intercourse. Whether or not that reduces sensation is impossible to compare once the foreskin is removed. Only the male himself is qualified to make that decision.

Now, to Morris' claims under "lack of circumcision" linked in Lauren's entry. He states:

Is responsible for a 12-fold higher risk of urinary tract infections in infancy. Risk = 1 in 20. Higher risk of UTI at older ages as well.

He provides no source for his claim of a 12-fold higher risk. I assume he's pulling this from a study by Thomas Wiswell, but I'm guessing, since he didn't source it. I have no idea where he found the risk to be 1 in 20. According to the more recent statement from the AAP, estimates are "that 10 of 1000 (1%) uncircumcised male infants will develop a UTI during the first year of life compared with 1 of 1000 (0.1%) circumcised male infants." Claims like "12-fold higher risk" don't look quite as compelling when considered in context. Also, females in the first year of life have a risk of UTIs equal-to or higher-than intact males. We treat those without surgery, even after they actually occur.

Confers a higher risk of death in the first year of life (from complications of urinary tract infections: viz. kidney failure, meningitis and infection of bone marrow).

I addressed this above with the hygiene issue, so here I'll take a different approach. What is that risk of death? Professor Morris does not state the risk, nor does he link to a source for his claim. I have no problem accepting that it's true, but are we debating a 50% risk of death from the foreskin? A 25% risk? Or are we discussing a risk significantly lower than 1%? I would wager the third option is closest to the truth. Ultimately life has risks. We can't live in bubbles to prevent bad things from happening, particularly when those bad things are very unlikely.

One in ~400-900 uncircumcised men will get cancer of the penis, which is over 20 times higher in uncircumcised men. A quarter of these will die from it and the rest will require complete or partial penile amputation as a result. (In contrast, invasive penile cancer never occurs or is extraordinarily rare in men circumcised at birth.) (Data from studies in the USA, Denmark and Australia, which are not to be confused with the often quoted, but misleading, annual incidence figures of 1 in 100,000).

The often-quoted figures are quoted by the AAP. I'm willing to consider that it's misquoted, and I'll correct if it is. But Morris does not show here how this statistic is misused. He merely attempts to scare us with a few numbers that are not impressive in the context of actual population sizes and risk factors. He expects the reader to accept his cost-benefit analysis, weighing the 400-900 and 200 against the 1,000,000+ infant males circumcised to achieve these results. I do not because we are discussing surgery on individuals, not groups. Actual human beings, with opinions, preferences, and needs are involved. I refuse to behave like an irrational collectivist.

Is associated with 3-fold higher risk of inflammation and infection of the skin of the penis. This includes balanitis (inflammation of the glans), posthitis (inflammation of the foreskin), phimosis (inability to retract the foreskin) and paraphimosis (constriction of the penis by a tight foreskin). Up to 18% of uncircumcised boys will develop one of these by 8 years of age, whereas all are unknown in the circumcised. Risk of balanoposthitis = 1 in 6. Obstruction to urine flow = 1 in 10-50. Risk of these is even higher in diabetic men.

Balanitis

Balanitis is easily treated. Practising good hygiene and avoiding substances that irritate the penis will often clear the balanitis. (See the Treatment section for more information).

The rest...:

Phimosis

Phimosis is when the foreskin is very tight and cannot be pulled back over the head of the penis (glans). It's normal for the foreskin to be attached to the head of the penis up until about age five. Parents should not try to pull the foreskin back because it can cause pain or injury. However, after the age of five, the foreskin will usually separate by itself and can be pulled back.

In some boys, phimosis can continue up to the age of 10 and, occasionally, it can continue into adulthood. Boys who have phimosis, and are under the age of six, do not usually require circumcision, but it may be considered after this age if the foreskin is damaged. Damage can happen as a result of severe or repeated infections. However, in the majority of cases, the foreskin will loosen naturally, with true phimosis (see below) only accounting for about 1% of cases.
...

Paraphimosis

Paraphimosis is a tight foreskin that cannot be pulled back, meaning the penis is squeezed, which causes pain. It forms a ring around the penis, cutting off some of the blood flow to the glans, and making it swell up. Doctors can sometimes treat paraphimosis by gently squeezing the trapped glans until the foreskin is able to slide over it. However, if this is not possible, circumcision may be needed.

I do not deny that risks exist, and that maladies occur. These conditions indicate a legitimate need for medical treatment. If parents must make a decision here, so be it. But the clear evidence is that these can - and therefore should - be treated with methods less invasive than circumcision, if possible. That is the reasonable medical approach to a permanent, irreversible decision.

Means increased risk of problems that may necessitate 1 in 10 older children and men requiring circumcision later in life, when the cost is 10 times higher the procedure is less convenient, and the cosmetic result can be not as good as when done in infancy.

Morris would circumcise 10 in 10 male infants to avoid circumcising 1 in 10 males later in life. He states that the cost is 10 times higher. The overall financial burden to society is unchanged, contrary to what he's trying to convey through fear. (Future financial burden is not a valid reason to circumcise a healthy child.)

Speaking strictly from a finance perspective, advocating for infant circumcision is the more expensive approach. His analysis is that the cost is 10 times 0.1 for his preference and 0.1 times 10 for his worst case. The present value of $1 spent over many years in the future is less than the $1 spent today. Professor Morris prefers the more expensive option.

Nor should convenience be considered. That is not a medical indication. If the male wishes circumcision more than the inconvenience, he will choose it. If not, it is not acceptable for parents to choose that for him, against his (probable, based on statistics) future choice.

As for cosmetic results, this is simply insane. Circumcising an infant places the parents' aesthetic sexual preference as the justification, even though the child may not choose it. He gets zero choice, and the cosmetic results aren't guaranteed to be good by whatever future subjective standards he develops. If he is left with his decision, he can decide if he values the risk of a poor cosmetic outcome versus his normal penis.

Increases by 2-4 fold the risk of thrush and sexually transmitted infections such as human papillomavirus (HPV), syphilis, chancroid and, in some studies Chlamydia.

And:

Is the biggest risk factor for heterosexually-acquired AIDS virus infection in men. 3 to 8-times higher risk by itself, and even higher when lesions from STIs are added in. Risk per exposure = 1 in 300.

And:

In the female partners of uncircumcised men is associated with a 5 fold higher incidence of cervical cancer (caused by sexually transmitted HPV), pelvic inflammatory disease, infertility from blockage of fallopian tubes, extopic pregnancy (each caused by Chlamydia), genital herpes, and other conditions.

Condoms and monogamy are necessary, regardless. Forcing circumcision on sexually-inactive infant males does not change the necessity of practicing safe sex when they become sexually active. At its core, this is merely a belief that males will be irresponsible and/or female health is more important than a male's normal body. It also assumes that his future female (or male?) partners will not be responsible enough to protect themselves from STDs.

The core evaluation is very simple. If the child is healthy, no surgery is indicated or justifiable. Chasing benefits for children is an illogical path that can be pursued to other irrational avenues and on both genders. It has no place in the proxy decision-making of parents for the genitals of their male children, as we already understand clearly for female children.

UPDATE: I corrected one point of grammar and added the word males to "1 in 10" for clarification. I also added if possible to my statement that less invasive treatments should be used to treat foreskin ailments. Circumcision is sometimes necessary, of course, but it should be used as the last option, not the first.

April 03, 2009

Who Needs Evidence?

I don't think much of Men's Health magazine after its recent, flawed article on male circumcision. This entry on the Men's Health Life blog still managed to disappoint. The author describes having his sons circumcised, yet manages to work in this sentence without any apparent awareness:

The beautiful, fragrant flesh of a newborn shouldn't mix with steel blades unless absolutely necessary.

And yet, he and his wife hired a doctor to unnecessarily take a steel blade to the "beautiful, fragrant flesh" of their newborn sons. Should anyone expect more throughout the rest of the article? After implying that the risk of severe complications is the only risk involved in circumcision, and comparing that to the risk of an individual getting hit by a rogue asteroid, the author attempts to defend his action with this:

Much more likely is the scenario that that beautiful boy grows up, is considered beautiful by another of our species (male of female), and begins expressing that attraction through sex. And that's when the superfluousness of the foreskin morphs into a decided health threat. ...

His foreskin is only a threat if he engages in unprotected sex with infected female partners.

Notice, too, the inclusion of "superfluous" to describe the foreskin. That's a subjective word. The foreskin has sexual functions, so its removal changes his sexual experience. Does the male himself consider his foreskin superfluous?

In the U.S., then, circumcision can be regarded as a worthwhile precaution against debilitating STDs later on in life. ...

The findings on circumcision involved voluntary, adult circumcision. I have no problem accepting that voluntary, adult circumcision can be regarded as a worthwhile precaution against anything, down to the owner's revulsion at his anatomically-normal body. That is not what the author is suggesting. His perception of the risk of STD for his sexually inactive sons is enough for him to make their decision. That's ignorant.

... In Africa, where AIDS runs rampant and garden-variety STDs are a contributing factor to transmission, circumcision is a humanitarian issue. ...

That's a very convenient reframing that ignores the actual epidemic in Africa. Unprotected sex with multiple concurrent partners is the problem. Circumcision status is possibly related only to the extent that individuals regularly ignore safe sex practices. Who wants to put confidence in that as a long-term solution?

If a small bit of skin is the only sacrifice needed to stop a humanitarian and health crisis, I say off with their heads!

When the person who makes the sacrifice and the person who makes the decision to sacrifice are different, the decision is unethical. Of course, as I mentioned regarding safe sex, circumcision is clearly not the only "sacrifice" needed. But call it a humanitarian issue and the circumciser becomes noble.

Still, this is the key paragraph:

But the N.O.C.I.R.C. people will be after my own head, now that I've joined the anti-foreskin forces. And listen, I understand their emotion. The penis is a sensitive body part, and babies are a very touchy subject. Combine the two, and people's forehead veins begin to bulge. But N.O.C.I.R.C.'s bellicose attitude toward the debate is pushing aside rational consideration of the evidence, and scaring parents into making decisions that are against the best interest of their babies. And society at large.

The only person pushing aside rational consideration of the evidence is the author (and every pro-infant circumcision advocate). Here is the proof:

The beautiful, fragrant flesh of a newborn shouldn't mix with steel blades unless absolutely necessary.

The child is healthy at birth. No indication exists for surgical intervention. Therefore, no intervention is justified. The only guarantee from routine/ritual infant circumcision is the child's exposure to surgical risk. That is not in his best interest.

If we didn't follow this, any intervention on children could be excused based on scientific studies on adult volunteers. The author claimed to believe that evidence matters, but he dismissed the fundamental evidence that was inconvenient to what he wanted to do. That is pushing aside rational consideration of the evidence.

Uganda Epidemic != United States Epidemic

I'm slow getting to this story, but the United States loves irrational fears when it comes to the foreskin, so it's still as relevant today. A re-evaluation of one of the studies used to claim that (voluntary, adult) male circumcision reduces the risk of female-to-male HIV transmission suggests that (voluntary, adult) male circumcision reduces the risk of herpes transmission by 25% and HPV transmission by 30%.

To the extent that adult males want to volunteer for these reasons, so be it. Everyone is entitled to his own decision. Personally, I'd rely on safe sex, not surgery. But that's not how the data are being used in the U.S. Here, it's predictably OMG 25% 30% OMG YOUR SON IS GONNA DIE A SAD HORRIBLE PAINFUL DEATH IF YOU DON'T CIRCUMCISE HIM BEFORE HE HITS THE DOCTORS HANDS IN THE DELIVERY ROOM OMG! OH AND WOMEN PREFER CIRCUMCISED PENISES WINKWINK. From one of the researchers involved:

Dr Judith Wasserheit went on to say: "All providers who care for pregnant women and infants have a responsibility to assure that mothers and fathers know that circumcision could help protect their sons from the three most common and most serious viral sexually transmitted infections, all of which cannot currently be cured."

Again, notice how easily Dr. Wasserheit dropped voluntary and adult from the study's results. If voluntary, adult circumcision was enough to protect the men involved in the study, surely the exact same is capable of protecting American males. Maybe she wants to suggest that the American STD situation is more dire than the situation in Uganda to justify dropping voluntary or adult?

But to her point, all providers for infants have a responsibility to assure that mothers and fathers know the objective status of their son's foreskin health. Almost always that will mean a statement that no intervention is indicated or warranted. There is no defensible reason to impose surgical risks for a surgery that is a) not needed and b) can be postponed until the child can choose. That was the ethical standard applied in the study. American public health officials have not explained why American infant males should be provided fewer ethical protections.

As the BBC journalist shows, it's possible to find different views. First, the key point that everyone forgets in the hysteria:

The reason why a foreskin might increase the risk of infection with various viruses is unclear.

Whatever the data reflect, this should not be forgotten. It's reasonable to consider the possibility that there is a methodological flaw, for example. What if improper controls existed? What if the timeline was too short? This should not be ruled out, which further highlights the already clear ethical flaw in pushing these results as an excuse to circumcise infant males. And what if the mechanism suggests that some level of female genital cutting would also reduce risks? Would the current advocates endorse that research, or are findings like the current re-evaluated study merely a solution in search of problems?

Dr Colm O'Mahony, a sexual health expert from the Countess of Chester Foundation Trust Hospital in Chester, said the US had an "obsession" with circumcision being the answer to controlling sexually transmitted infections.

He said: "Sure, a dry skinned penis is a bit less likely to contract HIV, herpes and possibly genital warts but it will get infected eventually."

That's what I mean by a flaw in the timeline. If a male has unprotected sex - the only way circumcision could provide protection - with HIV-positive females, he will become infected. The choices are condoms/monogamy/circumcision or condoms/monogamy. Circumcision is superfluous and unnecessary, so infant circumcision is indefensible.

Keith Alcorn, from the HIV information service NAM, also warned against a knee jerk reaction.

He said: "We have to be careful not to take evidence from one part of the world and apply it uncritically to others.

Given the U.S. reaction, it's too late for that.

"Male circumcision will have little impact on HIV risk for boys born in the UK, where the risk of acquiring HIV heterosexually is very low.

The same applies to the United States.

Faith versus Individual Rights (of Children)

For a few days I've mulled over whether or not I should comment on this story:

Accepting a plea bargain that her attorney described as unprecedented in American jurisprudence, a 22-year-old Maryland woman yesterday agreed to cooperate in the prosecution of other defendants in the death of her son under the condition that charges against her be dropped if the child rises from the dead.
...

The boy's mother, Ria Ramkissoon, is shaping up as prosecutors' star witness against a 40-year-old Baltimore woman named Queen Antoinette. Prosecutors allege that Queen Antoinette led a small cult, called One Mind Ministries, based in a West Baltimore rowhouse. In early 2007, prosecutors say, Queen Antoinette instructed Ramkissoon and others to deprive Javon of food and water because he didn't say "amen" before breakfast.

I'm inclined to make a comparison to infant circumcision for religious reasons. It's easy to make even though there are many steps between the two points, but I worried about the perception that I'm claiming a moral equivalence between circumcision and death. I am not, so I stayed away. Then I read this entry by Rogier van Bakel, which I think gets the angle correct (emphasis in original):

Yeah, no insanity there. I mean, since she felt compelled by God to let her baby die a drawn-out, miserable death, why would anyone question her mental capacity? That just wouldn't be respectful to the Big Guy, and to people of faith, now would it?

I'm more or less agnostic on religion, and I don't care what people believe. My only concern is how our civil government uses religion as a guidance on rules. Specifically, I'm concerned about how government treats what one person does to another in the name of religious faith.

This case demonstrates that we collectively believe our government must not rebuke religious intent in individuals who inflict objectively harmful practices on another. And we must punish only the most egregious examples. In America, belief in a higher being is a sign of increased rationality. We mistakenly accept that parents may undertake certain unjustifiable actions against their children because we do not wish to imply that the verifiable is superior to the unverifiable. That is wrong.

This case is obvious, so the deference to religion in pursuit of convictions is understandable, if not entirely acceptable. The mother is obviously incompetent, so we shouldn't pretend that she is. That will only perpetuate further violations of the rights of children because it gives religious justifications credibility they do not deserve.

March 21, 2009

On Widespread Gender-Based Double Standards

One more story for today that draws a parallel to the gender-bias in child genital cutting in America. (Note: The names of the minors should be redacted, but they're obviously known, so I'm leaving them in the excerpt.)

Alan Jepsen was playing videogames at his home in Sheboygan, Wisconsin, when the cops came knocking on his door. He was handcuffed in front of his sister and thrown in jail. In the words of his attorney, Jeffrey Purnell, “This child, this 17-year-old high-school kid, had to spend a week in jail—they locked him up and they put him in jail with grown-ups.”

His crime: Having sex with his 14-year-old girlfriend. And, perhaps, being a boy.

The day after Alan's arrest, Sheboygan authorities arrested Norma Guthrie, also 17, for having sex with her 14-year-old boyfriend. Norma, however, did not have to spend a single day in jail. She was released immediately, on signature bond, while Alan was held on a $1,000 cash bond, which his family could not afford. Sheboygan County Assistant District Attorney Jim Haasch is handling both cases.

The disparity in the punishment of these 17-year-olds, both accused of having sex with the 14-year-olds they were dating, goes much deeper. Haasch charged Alan with a Class C felony, which, according to court records obtained by The Daily Beast, carries a maximum prison sentence of 40 years. Norma, on the other hand, was charged only with a misdemeanor, which carries a maximum sentence of nine months in jail.

If the facts are as they appear, this is despicable. And entirely predictable. Males are viewed as possessing endless sexual appetities. Females are viewed as sexual victims. The typical defense of the non-existent ethical distinction between genital cutting on male and female minors rests solely on the mistaken notion that female genital cutting is strictly designed to limit the female's sexuality, if not destroy it completely. (And imposed by women, even when it isn't.) For males, we pretend that potential medical benefits dismiss the same ethical issues involved in female genital cutting because parents say their intentions are good. Anyway, we're told, males enjoy sex more than enough, and genital cutting doesn't affect male sexual experience. And if it does, although it doesn't, that's exclusively a good thing, except removing nerve endings couldn't possibly alter sexual experience, so why are you worried?

Here's an example:

Between 2002 and 2003, Turkish scientists studied how circumcision influences male sexual functions. They only studied men who were circumcised for aesthetic or religious reasons. The average age of those surveyed was 22.3 years old, and their sexual functions were equal before and after circumcision. After the survey was carried out, scientists concluded that circumcising grown men does not negatively effect their sexual functions. On the contrary, the fact that it causes a delay in ejaculation is more of an advantage than a complication.

Circumcision affects sexual function. It delays orgasm, which is an objective claim. Whether or not that is positive or negative is subjective to the individual, yet it's treated as an objective finding. It's not stated here, but most commonly the argument relies on some defense that women prefer this outcome, so it is good. (Check virtually any propaganda by Brian Morris or Edgar Schoen.)

If a man likes large breasts, he does not have the right to impose breast augmentation on his daughter to achieve this positive outcome. We understand that, of course, because it involves controlling a female's sexuality. But we embrace a double standard when the roles are reversed, even though the ethical issue is the same. We must not deviate from the belief that men are predators and women are delicate flowers. So, no, I'm not surprised that there is a double standard involving prosecution of these two Wisconsin teens.

Original link via Radley Balko.

New Jersey Worries About Body Hair Removal

I've seen this story floating around for a few days, from multiple sources.

Things could get hairy in New Jersey this summer for women who sport revealing bikinis or a little bit less.

The painful Brazilian wax and its intimate derivatives are in danger of being stripped from salon and spa menus if a recent proposal to ban genital waxing is passed by the state’s Board of Cosmetology and Hairstyling.

Before I get into my brief take, I'll stress what I think explains this, which is what Brad Warbiany pointed out at The Liberty Papers:

[Cherry Hill, New Jersey salon owner Linda] Orsuto said that the proposal may be the state's way of diverting a long-established salon procedure "perfected by aestheticians" to the medical community, where hair can be removed via laser treatment by dermatologists.

As Mr. Warbiany stated perfectly:

Follow the lobbying money.

Those four words explain most government actions, no?

**********

My take: If this passes, it will be illegal in New Jersey for a woman to have her pubic hair waxed from her genitals, but she will still be free to have her son's healthy foreskin surgically removed for any reason she can imagine. We have a long way to go before people understand individual liberty.

Check Your Premises

From England:

It took a death threat to stop Abdi’s wife from circumcising their two daughters, aged 2 and 4. She called him from Somalia while on holiday to say she wanted to carry out the procedure.

Abdi, a London-based Somali, said that his wife’s eagerness to circumcise their daughters was fuelled by a combination of religious, cultural and tribal pressures placed on her after she took the girls to Somalia for a brief summer break last year.

But he refused to be swayed, despite his wife’s argument that the girls would improve their chances of attracting a good husband because they would be perceived as being more traditional and pure.

First, notice the third paragraph. I can't and won't begin a detailed analysis because it would be speculation, but the information there suggests that this reasoning is at most a difference of degree between this and what Western parents often choose for their sons. The focus is on how to make the child more attractive to a future partner, not what the child needs. Attempt to build a defense of infant male circumcision on the grounds of potential benefits, but ultimately this reasoning must make no distinction between those alleged-but-not-really medical reasons and the nonsense that what the child's future sexual partners might want is relevant to what to do to his genitals. The whole notion is absurd.

Second, this one example proves nothing. However, it demonstrates that those who perpetuate the belief that female genital cutting is exclusively perpetuated by men are mistaken. At some point we have to lay down our agenda of blame and figure out how to stop these violations. I suspect the desire to blame is responsible for much of the inability to see the similarities between male and female genital cutting. Medically unnecessary genital cutting on a non-consenting person is unethical. That is a statement of principle free from the ramifications of gender-specific reasoning and outcomes. It considers only the victim. That's what matters.

March 14, 2009

Public Health Officials Always Know Their Conclusion

Stories like this warrant mentioning because the hypocrisy isn't going away:

Suriname has launched a three-month pilot project offering free circumcisions in a bid to cut sexually transmitted diseases, Health Minister Celsius Waterberg said Friday.
...

Some two percent of the Suriname population is HIV-infected, about 10,000 people, and the project aims to carry out the operations on 100 men aged between four and 21 years old over the next three months.

How many four-year-old men do you know? When public health officials discuss the potential reduction in HIV risk from voluntary, adult male circumcision, they always forget voluntary and adult. Always.

If successful then the project will spread nationwide, Waterberg said.

This circumcision program seeks to reduce sexually-transmitted HIV infection because three studies determined that (voluntary, adult) circumcision reduces the risk of female-to-male HIV infection through vaginal intercourse. By what standards do you think the program's coordinators will use to judge the program successful in reducing HIV transmission among the four-year-olds? When will they reach their conclusion?

March 12, 2009

On Ross Douthat Joining the New York Times

The Atlantic's Ross Douthat is the new conservative columnist for The New York Times. I haven't read enough of his work to suggest that this is unwarranted. And he is, in fact, a talented writer. It's just that I've been unimpressed with his thinking whenever I've encountered it. He shows very little interest in liberty or constructing a government that respects the interests of those with whom he disagrees.

In this entry from early last year, I criticized Mr. Douthat's thinking on two topics, prostitution and infant circumcision. His position in both cases was objectively weak, at best. I'll leave you to follow the link for my challenge to his views on prostitution. Here, I'd like to repost what I wrote in response to his tongue-in-cheek-yet-mind-numbingly-stupid view on infant circumcision.

**********

Of course, since it's apparently okay to ask questions unrelated to the topic, let me ask a question: Why is it automatically self-harm worthy of prohibition for an individual to sell sex, even when it's voluntarily sold, yet it's reasonable to permit parents to surgically alter the genitals of their healthy sons - who may or may not approve of such permanent, physical alteration - as Mr. Douthat suggested last year in defense of infant circumcision?

The answer to how one person can hold two incongruent opinions rather obviously rests in a willingness to use personal, subjective tastes and preferences to inform the legal code of a diverse, secular, civil society. It's the same central planner impulse that resides in every individual who seeks to dictate which freedoms are abhorrent.

Since I'm off on the tangent, in that entry, Mr. Douthat states:

Proponents, like myself, point out that even saying the word smegma is really disgusting. Again, I think we pretty much win the debate right there, without even getting into the whole HIV question.

I get the tongue-in-cheek nature of the comment, whether he meant it or not. I think he did because I think he views circumcision as inconsequential. (Remember subjective tastes and preferences?) But any understanding of human biology demonstrates the stupidity of such an argument. Female genitals produce smegma, as well. We do not cut female minors for that reason. Or, more to the point, we do not permit parents to cut their daughters just because they, the parents, are disgusted by the mere mention of the word. We manage to find the correct reasoning to prohibit that. But for males, parents can use only the mere mention of smegma as an excuse to cut. Or they can reject even that reason and order it because it's fun to check "yes" on the consent form. The law is based on our conditioned beliefs rather than facts.

**********

This wasn't in my original response, but it warrants a comment in light of the weight Mr. Douthat's opinions will now receive because he is a columnist for The New York Times. From his entry on circumcision (emphasis in original):

... I believe I have the weight of the American experience on my side when I say that any such dampening [of sexual pleasure] would have to be extremely negligible.

He proves that he can't possibly know this from experience with his next sentence:

All of which is to say that I'm gratified that my parents took it upon themselves to have a procedure performed on my infant self ...

Without any sexual experience with his foreskin, he knows it's "extremely negligible". How? "I have experience with one side of the debate, so I am an expert on both sides of the debate" is not a sign of a great thinker. It is a sign of a mind interested in selecting the necessary facts to reach a desired, self-centered conclusion. I'm unimpressed.

March 11, 2009

Limited Government Is Less Prone To This Flaw

I'm trying to figure out a way to criticize Michael Gerson's column in yesterday's Washington Post that properly registers the obliviousness to the contradictions of his protests. If I spent enough time to develop something pithy, it would be scathing. Instead, I'll jump into his opening paragraphs:

There is a common thread running through President Obama's pro-choice agenda: the coercion of those who disagree with it.

Obama has begun providing federal funds for international groups that promote or perform abortions overseas. He has moved to weaken conscience protections for health-care professionals. And he has chosen the most radical possible option on the use of embryonic stem cells -- a free license for researchers, with boundaries set only by the National Institutes of Health.

So, when the president wants to use public funds to pay for abortion, we must think of those who disagree with abortion. But when the president wants to direct public funds to faith-based organizations, Gerson misses the flaw. When the president wants to direct public funds to pay for circumcising healthy African infant males, Gerson misses the flaw. What's good to Michael Gerson is apparently all that's good, and you should pay for it, too. But how dare you not place limits on government for issues that he opposes.

Michael Gerson is a hypocrite.

March 03, 2009

Individual Incentives Can Be Skewed

When I wrote about comparative effectiveness research, I focused on the merits of including funding in the deficit spending bill as a path to more socialized health care. I haven't changed my opinion on that, but it's worth noting that the idea behind this research is reasonable. Do our interventions produce results?

Following that, here's an interesting analysis of comparative effectiveness research that focuses on the relevant issues (link via Kevin, M.D.). The analysis contains useful examples, and is worth reading. I don't think we'll get what we expect from the newly-funded research unless we expect more decision-making power handed to bureaucrats. Still, the idea behind comparative effectiveness research is reasonable.

But the more useful, immediate discussion is this:

Here’s where things get dicey. A chief medical officer I know was once discussing unnecessary procedures in his healthcare system. In a rare moment of unvarnished truthtelling, one of his procedural specialists told him, “I make my living off unnecessary procedures.” Even if we stick to the correct side of the ethical fault line, doctors and companies inevitably believe in their technologies and products, making it tricky to get them to willingly lay down their arms. ...

You can probably figure out that I'm going to discuss this in the context of infant circumcision. First, let me make this clear, in case anyone's missed me saying it previously: I do not believe there is a conspiracy to circumcise infant males. It is a common, actively-pursued goal, but it does not fit the nefarious intent behind a conspiracy.

That does not mean that individual doctors are immune to the undeniable point that genital surgery is not indicated for most infant males. The ethical claim is impregnable to excuses based in cultural and moral relativism. What incentive does a doctor like Dr. Neil Pollock have to begin deferring to his patients' needs rather than his own?

Dr. Neil Pollock, who performs about 2,500 infant circumcisions annually in Metro Vancouver, travelled to Rwanda in December to teach his circumcision method to local surgeons.
...

Pollock is hopeful that the painless [ed. note: Even if true, the ethical claim must win out.] nature of his technique, which takes less than a minute to perform, will persuade many Rwandan parents to consider circumcision for their infants.

Once again: When public health officials discuss the potential reduction in HIV risk from voluntary, adult male circumcision, they always forget voluntary and adult. Always.

Looking at comparative effectiveness research, Dr. Pollock is based in Vancouver, British Columbia, outside the realm of the deficit spending bill's reach. He's good anecdotal evidence, though, because he shows what it means to be uninterested in placing your patient's needs and rights first. He's built a practice around performing more than 12 infant circumcisions per business day. Will he readily give that up, since he's so clearly invested in continuing the involuntary procedure?

Of course, the conclusion on infant circumcision is already in. Here's what the Canadian Pediatric Society says about routine infant circumcision:

Recommendation: Circumcision of newborns should not be routinely performed.

I see no reason to believe there will be any difference in the US. Most American doctors already ignore the ethical case for protecting the rights of infant males. There are people invested in perpetuating the imposition of unnecessary genital cutting. No government study is going to change that.

February 25, 2009

Did you know you'd bought this?

Do you want to want to pay for another man's circumcision? Too bad:

Top on the Ministry of Health’s five-year strategy is the free circumcision, to be made available in all public health centres.

Sh960 million from the US government has been injected into the project to buy surgical materials, mobilise communities and provide counselling. With a budget of Sh2,000 for each volunteer, the campaign targets 500,000 uncircumcised men in Kenya.

I'm not naive enough to think that men means males who've reached an age of consent. But I'll assume that's what it means for this story. Given that 500,000 is a very large sample, how many men do you think we'll pay to develop this attitude?

The Kenyan government launched a campaign to promote male circumcision in 2008, but it has not yet reached most parts of the country. In the northwestern district of Turkana, where the practice is not part of the culture and few have even heard of it, IRIN/PlusNews spoke to Isaac Ikone, 22.

"The government has not yet come here to talk about male circumcision, but I have heard about it from friends. They say it prevents HIV and sexually transmitted diseases. If that's true, I would definitely go for it so I can remain healthy.

"A while ago a friend and I found out we had the same sexually transmitted disease, and when I began to wonder how that happened, he told me he had slept with a girl I had also slept with in town. He is the one who told me that if we were circumcised, we would not have got sick.

"My girlfriend is still in secondary school and when she is not around I try to abstain from sex, but I'm not always successful. I don't like condoms; if there is a better way to prevent HIV so that I can enjoy sex skin-to-skin, I will do it.

Yes, it's anecdotal. It's also where we end up when we push circumcision as a panacea for genital diseases. Responsible behavior gets lost. And I'm being forced to pay for this, which will ultimately further entrench a human rights violation when it leads to more infant circumcisions.

As it will, because the push for infant circumcision is purposeful. This is from Uganda, but the sentiment is universal:

Most men and women in Uganda support medical male circumcision as a way of lowering HIV risk, and up to 62 percent of uncircumcised men would consider being circumcised, a new study has found.

The study, conducted by Uganda's Makerere University and Family Health International, which works to promote reproductive health, with funding from the United States Agency for International Development, surveyed 1,675 men and women in four districts; the results were released in the capital, Kampala, in December 2008.

Support for circumcising sons was even greater: almost 100 percent of circumcised men supported the circumcision of their male children, while 59 percent to 77 percent of uncircumcised men were in favour of having their sons circumcised, and between 49 percent and 95 percent of women wanted the procedure performed on their male children. [emphasis added]

I don't think this is a conspiracy. Those public health officials who ignore what the individuals want probably have good intentions. They're pursuing it because they know it works. Our government is happily joining the ride.

And what about those children who will be circumcised as a result?

"The purpose of the research was to find out what is on the ground regarding the capacity to conduct medical male circumcision, and its acceptability among the public," said Dr Alex Opio, assistant commissioner for national disease control. "It was also done to pave the way for developing a policy, because all policies need evidence."

An opinion poll somehow qualifies as evidence. What the individual wants is irrelevant, subjugated to the opinion of his parents. This is what it looks like to start with an outcome and create the necessary support.

February 23, 2009

Legislating for All Based on the Extremes

Oklahoma lawmakers think eyeball tattoos are a dangerous menace:

Senate Republican Whip Cliff Branan said, "Kind of a counter culture trend, the same folks may chose to pierce certain body parts, it's kind of the next level up."

Senate Bill 844 has unanimously passed through the Health and Human Services Committee. Oklahoma City Senator Cliff Branan says it was brought to him by the Oklahoma Academy of Opthamology. He says it's becoming more trendy to tattoo eye liner or eye brows, but this goes too far.

"It is completely patently disgusting and crazy to do it. We as a good public health policy we felt it was important to stop that trend before it goes any farther here in the state of Oklahoma," Sen. Branan described.

In 2006 Oklahoma's infant male circumcision rate was 72%. Parents in Oklahoma may freely surgically alter their child's son's healthy genitals for any reason, and a majority do. That's acceptable in Oklahoma. But an adult willingly choosing to tattoo his (or her) own eyeball is unacceptable because it is "patently disgusting and crazy".

Our society is not sane.

Via Nobody's Business.

Put on Your Editor's Cap

Imagine you work for Reuters and this study crosses your desk.

Conclusion.The key factor associated with acquisition of HPV was lifetime number of sex partners, whereas circumcision was the most significant determinant for clearance of any HPV infection and oncogenic HPV infection.

You deem that worthy of a write-up. How do you write that up? If you highlighted the greatest risk factor the study identified, you'd be thinking like a responsible journalist. You'd also be unqualified to work at Reuters, apparently, as the story (run by Fox News) shows:

Men who are circumcised may be more protected against persistent infection with the virus that causes genital warts, a new study suggests.

The study, which followed 285 men ages 18 to 44, found that among those who became infected with the human papillomavirus (HPV), circumcised men were more likely to have their immune systems "clear" the virus by the end of the 18-month study.

When it came to the risk of acquiring the virus in the first place, the biggest risk factor was having a large number of lifetime sex partners, the researchers report in The Journal of Infectious Diseases.

The story waits until the third paragraph to present the largest finding, and then it's only as an afterthought. The key lesson we're supposed to take is that circumcision appeared to protect men. That's bias, a conclusion seeking support.

Yet, notice how the article must clarify. The risk is identified "among those who became infected". Isn't that a useful key? We know how men (and women) can protect themselves. Don't sleep with lots of people. Wear a condom. Actions have consequences.

If adult men want to use this study to justify circumcising themselves, I don't care. I think it's unnecessary because there are better ways to protect themselves. Someone else might think differently. But that's not the point of headlines like this. It seeks to push infant circumcision. "See, it has medical benefits," proponents claim. It's propaganda wrapped in the appearance of good intentions.

February 20, 2009

Clarifying Circumcision Facts, Part 1

I've been in an on-and-off circumcision debate on Twitter recently with an individual named NotStyro. (My Twitter link.) I find the debate useful because I find his responses inadequate. However, 140 characters isn't enough to debunk the flaws in the link he typically provides. I have a different qualm, but first, a representative tweet from NotStyro on the subject.

just to inform, not debate... [link redacted] ...let me know if you would like more information

I find this understandable within the limitations of Twitter, but unsatisfactory overall because the site he links makes this offer:

Why should you consider circumcision ?

With the anti-circumcision propaganda on the net, consider the following facts:

If parents will make a choice (that isn't ethically theirs), I want more than a list of seven facts of questionable legitimacy. To the extent these facts are facts, they still do not support what NotStyro recently promised a father questioning his son's pending circumcision to go forward with the surgery:

... he'll appreciate your decision later in life.

As he's been in our debate, NotStyro is indifferent to the reality that men, including me, do not appreciate that decision by our parents. This is our fundamental disagreement. I demand only that each individual retain the choice to decide about his body. NotStyro argues differently. But we can't get to it until we agree on facts.

There's too much information in his link for one post, so I'm going to break this up into its logical parts. The list NotStyro links to has seven items. Each item will get an entry. Once I've posted an entry, feel free to debate (i.e. defend) a position. No e-mail or web address is necessary to comment. I'm establishing only one rule beyond normal etiquette: inappropriate links will be deleted. Most links will stay if they're defended. (No canned answers, please; address the items from the list.) But I will not allow a direct link to the list of seven items under any circumstance. The site is a pro-circumcision fetish site, complete with circumcision fiction. I will not promote it. If you must visit it (NSFW), follow the link through NotStyro's tweet above. Anyone may participate, of course. To NotStyro directly, I'm asking for more information.

On to item #1:

1. The foreskin increases the risk of male and female infections.

  • 'Current new-born circumcision may be considered a preventative health measure analogous to immunisation in that side effects and complications are immediate and usually minor, but benefits accrue for a lifetime’

"May be considered" is a claim, not a fact. Nor is infant male circumcision analogous to immunization. The threats are distinct. Unvaccinated, I could catch measles by simply going out in public. I am not going to become HIV-positive without specific sexual behavior I can control, regardless of whether or not I have my foreskin.

There is a further complication to the comparison. The recent, actively-touted studies looked only at female-to-male HIV transmission. This is the least common transmission among those involving men. For example:

Female-to-male HIV infection was not observed in long term stable monogamous relationships. These results emphasize the relative uni-directionality of heterosexual transmission in non-promiscuous couples.

That suggests what we already know. HIV is transmitted through promiscuous, unprotected sex. Pretending that circumcision is a significant benefit when neither of those conditions exists is wishful thinking. Circumcised or not, if an individual behaves recklessly, there are consequences. That is the lesson. Parents will be more successful at keeping their sons (and daughters) safe from HIV if they teach them about responsible sexual behavior. No medical expert proposes that circumcised men may now ignore condoms. Circumcision is superfluous and unnecessary. This is particularly true in the United States, where HIV infections result primarily from IV drug use and male-to-male transmission. Circumcision is irrelevant to the former and ineffective to the latter.

The rest of the claim is questionable, as well. Minor complication is subjective, as determined by the victim. You may think a skin tag is "minor"; I would not. I prefer to think of complications as treatable and not treatable. In this case, yes, most complications are treatable. That raises the obvious ethical question of imposing surgical risk on a non-consenting, healthy individual, which I will save for another post in this series.

But what about those complications that are not treatable? These can be lesser problems such as tight, painful erections. If we move up the spectrum, we can discuss males who lose portions or all of their glans. Are we still in the territory of "minor"? What if we go to the extreme, death. It happens. I won't pretend it happens often, but how many times may it happen before we suggest that maybe healthy boys dying from by-definition unnecessary surgery is unacceptable? The lack of medical need demands the answer be 0. It isn't, which demonstrates that we do not rely on facts when circumcising healthy infant males.

Continuing from the list:

  • Circumcision reduces the risk of vaginal infections.

Probably, based on some of the studies I reviewed. If, of course, the results were properly controlled and the results are transferrable to industrialized nations. Maybe, maybe not, but I'll concede the point for argument's sake. This is a factual claim. So what?

The underlying issue here is the ethical flaw. It is unethical to alter a non-consenting individual's body to reduce the risk that his future partners - if he is heterosexual - will suffer vaginal infections. That is a decision for him to make. He may include his female partners in the decision-making process. But that is within only his discretion. All else is a speculative guess. A speculative guess involving another's healthy body is indefensible, even if his parents make the speculative guess.

To put it in perspective, a male can't cause vaginal infections if we prohibit him from having sex with women. He can't cause vaginal infections if we remove his entire penis. These are extreme, ridiculous hypotheticals. But they demonstrate that just because we can do something does not mean we should. There is more involved in permitting parental proxy decisions than just the fact that Action X generates Result Y.

Whether or not this generates a debate, and how long that debate transpires, will determine when part 2 appears. I will continue the series, regardless.

February 16, 2009

Is this a defensible thought-process?

I want to pass along an e-mail sent to David Wilson of Stop Infant Circumcision Society. There is rough language throughout, but it demonstrates a valuable point. [sic everywhere]:

I've seen the nasty ass excuse of a dick you rocket pop weilding bastards have I love my circumsized penis it is the prettiest dick I've ever laid my eyes on it doesn't smell if I miss a shower either you sick fuck why would you want to inflict a circumcision on a full grown man any way have you seen the process fuck you my dick is gorgeous I love my wang and I sure as fuck wouldn't of made the decision myself as an adult what kind of a fucked up world are you trying to create where an eighteen year old has to decide weather a mental scar like that is worth hygene

I am told that the choice to circumcise only male children for non-medical reasons is a parental right. This is objectively wrong, and this e-mailer is the too-typical anecdotal proof. I will posit that he is not qualified to make medically necessary decisions for a child, so medically unnecessary, permanent decisions should be prohibited. Despite this easy-to-understand truth, he is allowed to circumcise a male child with this thinking because no politician or judge has the courage to reject the status quo and defend the individual rights of all children. Our society is not yet sane on this topic.

February 15, 2009

Press Release: An Instrument of Distortion

I loosely follow a rule in my blogging that I don't bother with press releases. They're skewed to push the angle of whoever is paying the bill. It might be worth picking out the propaganda from a press release to find the facts, but I can usually achieve that with less effort by going to news sources to make a point. (Of course, most news sources reporting on circumcision are filled with propaganda, too.) Generally a press release is only good for demonstrating propaganda. This recent press release is a good example:

Hospitals in states where Medicaid does not pay for routine male circumcision are only about half as likely to perform the procedure, and this disparity could lead to an increased risk of HIV infection among lower-income children later in life, according to a UCLA AIDS Institute study.

The first half is fact. The second half is conjecture. News, then propaganda. The HIV-circumcision studies researched the effect of voluntary, adult male circumcision in reducing the risk of female-to-male HIV transmission from heterosexual intercourse. It is inaccurate to draw the conclusion that the foreskin puts men at higher risk of HIV. Unprotected sex with HIV-infected partners increases an individual's risk of HIV infection. The male must first engage in that specific activity to become infected. Focusing on the foreskin distracts from efforts to reduce such behavior.

But that doesn't sell the way fear sells.

But recent clinical trials in South Africa, Kenya and Uganda have revealed that male circumcision can reduce a man's risk of becoming infected with HIV from a female partner by 55 to 76 percent. In June 2007, the AAP began reviewing its stance on the procedure.

By now you know what was left out of that summary, right? When public health officials talk about voluntary, adult male circumcision, they never mean voluntary, adult. Never.

As the press release so helpfully theorizes in its opening line:

Lack of coverage puts low-income children at higher risk of HIV infection

Think of the (poor) children. That's not very original. It has the added bonus of being inaccurate. Are these children sexually active? Specifically for the age of the children discussed in this press release, the answer is no for 100% of them. They are not at risk of (female-to-male) sexually-transmitted HIV infection. But those necessary, contradictory details must be ignored. Think of the (poor) children.

That is how propaganda is done.

**********

Not to let an opportunity go to push for a collective response to an individual problem, the Family Planning Cooperative Purchasing Program helpfully regurgitates this press release, with the necessary bits of speculation helpfully emphasized in bold. An example:

In addition to the overall lower circumcision rates, the researchers found that the more Hispanics a hospital served, the fewer circumcisions the hospital performed. For Hispanic parents, the circumcision decision was about more than simply cost, since male Hispanic infants were unlikely to receive the procedure even in states in which it was fully covered by Medicaid.

What point is FPCPP trying to make with that emphasis, given the sentence that follows it? The only justification I infer is an implicit suggestion that we need to encourage Hispanics to "Americanize". That wouldn't surprise me because it's the typical, mindless support for non-therapeutic genital mutilation in America. And FPCPP files this under "Public Policy", among other categories. See above re: voluntary and adult. If it's not that, I'm stumped.

**********

You and I, through a grant from the National Institute of Mental Health, paid for this research. Mental Health? With mission creep like that, who could possibly worry about government-run health care?

However, this raises the question of national health care and the future of routine infant male circumcision in America. I've long held that the former would not end the latter. The political environment for defending non-therapeutic circumcision is too strong, as evidenced by studies like the one leading to the above press release. No politician is going to say that parents can't circumcise, despite the clear constitutional flaw in our status quo.

Ending public funding isn't sufficient. The state should not pay for mutilation, but fails to end the practice. Poor parents pay for the surgery out-of-pocket. They complain about it, citing the potential benefits as an excuse for why Someone Else should pay, but they pay the cost anyway. Their sons are not protected by their state's lack of Medicaid reimbursement. And ending government reimbursement doesn't always end government reimbursement, as Minnesota's politically-motivated solution showed.

Still, I need to have a think on my position. I won't suddenly support government-run health care, but I should explore the nuances further.

Linkfest

LINK: Think government manipulation of intervention in the economy is good? Read George Will's latest column. (H/t: Cafe Hayek)

LINK: Jim Harper has an entry on Cato @ Liberty discussing President Obama's pledge to post all bills for 5 days of public comment before signing them. Mr. Harper reviews the steps the administration has taken and offers a positive review of the idea, although he correctly criticizes the administration for playing loosely with the 5 day timeline.

I agree with that in principle, but that's not my concern here. The deficit spending bill mistakenly labeled The American Recovery and Reinvestment Act of 2009 is now online for public comment. I thought about adding comments, but why? I'm realistic enough to understand that what I say will not matter. It will not matter how many people comment against it, this is a done deal. The five days concept as implemented is worthless political propaganda. Honestly, if members of Congress can't be bothered to read the bill, yet they'll happily vote by party line, they don't care what the American people think. They're trading favors for power. The game hasn't changed. So, wake me when this fails and tell me what the next stupid idea is.

LINK: I reject non-therapeutic infant circumcision because it is logically and ethically unacceptable. I question the science surrounding claims, particularly those involving HIV risk reduction, because there are obvious holes in the argument. However, unlike (too) many activists, I have no problem with vaccines. I think the logical and ethical arguments differ, and I don't believe in conspiracy theories about Big Pharma. And from what I've read, the autism-vaccine link appears weak, at best. This report seems to confirm that (link via Kevin, MD):

THE doctor who sparked the scare over the safety of the MMR vaccine for children changed and misreported results in his research, creating the appearance of a possible link with autism, a Sunday Times investigation has found.

I would use this as a lesson for everyone who thinks that a claimed HIV risk reduction for (adult, voluntary) male circumcision need to be concerned about the long-term reality of their idea. I think we will eventually look back on the HIV-foreskin connection and realize the mistakes in the studies. But I do not approach the topic from that angle. I don't need it, of course. I can concede the point for the argument and rely on ethics and objective indications of health and easier methods prevention.

For now, it's too late anyway. The link has gained widespread acceptance because people want to believe it, regardless of facts or reasonable caution. The mindset is the same, as this excerpt from Orac's post at Respectful Insolence suggests. (I read the post, but there's too much to parse easily, so I'm using the summary pulled by Kevin, MD.)

"None of this will matter to antivaccinationists," he writes, "who view Wakefield as . . . a persecuted scientific hero . . . I'm sure that [anti-vaccine proponents] will wax ridiculous about what a great doctor and man Wakefield is and how it's big pharma and its minions who, frightened by the implications of Wakefield's work, are working hard to demonize him and suppress his 'science.'"

When emotion precedes logic in an objective debate, reason is lost. That would be unfortunate but defensible if it only affected the decision maker. It does not. The individual fears of parents results in poorly conceived decisions for children. Vaccinate but circumcise. Don't vaccinate and don't circumcise. Neither combination is justifiable when weighing the evidence with logic and ethics.

LINK: To lighten things up just a bit, will the Mets never learn?

"Whatever they did last year, they already got paid," [Francisco] Rodriguez told the New York Daily News. Whatever they did, I have all the respect in the world. They worked hard and they deserve it. This is a different year and different ballclubs now. I don't want to make any controversy, but with me and (J.J.) Putz and the additions in the bullpen, I feel like now we are the team to beat."

K-Rod should ask Carlos Beltran how that worked out last year. However, I love this rivalry.

February 14, 2009

From the Archives: The Ethics of Vanity, Part III

The madness continues [emphasis added]:

About 150 patients in the U.K. have already received injections of Vavelta, a foreskin-derived skin treatment aimed at rejuvenating and smoothing skin withered with age or damaged by scarring from acne, burns and surgical incisions, according to a spokesperson for Intercytex, PLC, the Cambridge, England-based company that makes the product. The U.S. Food and Drug Administration (FDA) has not approved Vavelta, nor have any other federal agencies outside the U.K., where it was introduced in June 2007.
...

The fibroblasts in Vavelta are isolated from the foreskins taken from baby boys [ed. note: healthy baby boys], given several months to grow and multiply in the lab, and then packaged into treatment vials that are shipped to a select group of U.K. physicians. Each vial costs approximately 750 pounds, or $1,000], according to the company spokesperson.

I discussed Vavelta in November.

----------

Last week I saw news links similar to this article.

It sounds like just another uber-meltable cheese product, but Vavelta is actually miles away from anything you'd want to put in your mouth. It's a radical new treatment for facial pitting, scarring, and wrinkles made out of—what else?—newborns' foreskins.

I didn't write about it because it's just a new example of something I've discussed before. And, while I'm happy an ethical issue appeared in the article...

There are also ethical issues to consider, especially if the folks behind Vavelta start paying parents for their sons' severed sheaths.

... it hints at the wrong ethical issue. Parents do not own their sons' foreskins. That's why they don't have the right to cut them off, much less demand payment for them. If a similar value worked for freshly circumcised adult foreskins, adult males should be free to sell for the highest price. They're not, because the state thinks selling parts of your body is "wrong". But taking healthy, functioning body parts from a child for no objective reason without his consent? That's somehow a valid parental choice. It's madness.

----------

There was more in the original post, but it's not necessary to repeat for this. I'll add that discarded foreskins from adult males do not work well for this procedure. That changes nothing surrounding the ethical argument that demands stopping this practice.

February 12, 2009

Australia Imports American Nonsense

Arguing in favor of circumcising male infant to reduce their risk of HIV infection is flawed thinking, even in places like Africa. It's exceptionally ridiculous when looking at the extent to which pro-circumcision advocates bypass logic. From a recent Reader's Digest Australia article on male circumcision, included in the section labeled "Verdict", this quote:

"‘If it ain’t broke, don’t fix it’ is the understandable attitude of many Australians," says [University of Melbourne] Professor Roger Short. Yet he questions this wisdom. "Australia is blessed with a low prevalence of HIV infection, but parents need to remember their children will encounter high rates in many countries they visit."

How does he know male individuals will visit other countries? How does he know that those countries will have high rates of HIV infection? How does he know male individuals will have vaginal intercourse with HIV infected women? Where logic demands a different conclusion, Professor Short relies on propaganda. He began with his conclusion and grasped for assumptions to build around that to defend what is objectively indefensible.

**********

That's unsurprising because the article is structured to reach one conclusion. Among the arguments offered in favor of circumcision, the article includes "Appearance":

Research by Professor Marvel Williamson from the School of Nursing at Oklahoma City University found women prefer the look of a circumcised penis. "Generally women said it is more sexually appealing," says Williamson. "Ninety per cent of women said it looks sexier and 85% said it’s nicer to touch."

This is a non-medical argument used to excuse surgery on a non-consenting, healthy child. It's also a subjective criterion that will be irrelevant to the 10% and 15% of women, respectively, who disagree with the majority. It will also be irrelevant if the male is gay. This conclusion also demands that we accept an external locus of control for all male sexuality. What the society wants matters more than what the individual wants for himself. Human rights belong to the individual, so we must reject all of this.

But look at what the article explicitly ignored. It's obvious by the location of the research. A quick scan of the study reveals the omission.

This study clearly support the hypothesis that American women prefer circumcision for sexual reasons. The preference for circumcision does not necessarily come out of ignorance nor from lack of exposure to uncircumcised men.

Yeah, noting that the conclusion concerns American women might help Australian parents, except Australian statistics look nothing like American statistics in 2009. Also, this assumes that the mother's preferences - or the father's opinion about his own penis - matters. We're not assuming that because it doesn't matter. Professor Williamson incorrectly thinks it does, as shown in the design of her study:

Of 145 new mothers of sons responding to this survey, ...

Are we really so stupid that a parent's opinion on the sexual aesthetics of a child's genitals is considered a valid reason for surgical alteration? I want to believe we are smarter, but the evidence is very clear that parents can and do use this excuse. That position is indefensible. Remember that all tastes and preferences are subjective, unique to each individual. The choice on whether or not to allow the subjective tastes and preferences of his future sexual partners to influence his decision regarding cultural, medically unnecessary circumcision must be left to him. Ethically, parents may offer proxy consent to circumcision only when medical need exists, and then only when less invasive solutions are insufficient.

February 11, 2009

An Imaginary Distinction

UNICEF is promoting efforts to end female genital mutilation. This is good. But I'm predictably distracted by the news release.

Female genital mutilation or cutting is the partial or total removal of the external genitalia – undertaken for cultural or other non-medical reasons – often causing severe pain and sometimes resulting in prolonged bleeding, infection, infertility and even death.

Male genital mutilation or cutting is the partial (and sometimes accidental total removal) of the external genitalia - undertaken for cultural or other non-medical reasons - often causing severe pain and sometimes resulting in prolonged bleeding, infection, and even death. I narrowed the reality of total removal and ommitted infertility. Neither of those changes is sufficient to introduce the gender bias that so many demand. Yet, that is exactly what organizations like UNICEF insist upon because (adult, voluntary) male circumcision may reduce the risk of female-to-male HIV transmission during unprotected intercourse. Despite its claims, chasing potential benefits is not a valid medical reason to circumcise non-consenting, healthy individuals - including male children.

John Harvey Kellogg's Legacy

The "OMG Michael Phelps smoked marijuana" story is still a hot topic, with the general tone thankfully being that this is hardly worth wasting the effort of any brain cells. I concur, but that won't stop the usual idiots from moralizing. The extends a little further to at least the appearance of moralizing, as evidenced by Kellogg dropping its endorsement deal with Mr. Phelps. I regard this as nothing more than a business decision. It's weak and cowardly, but nothing in my support for capitalism suggests that individuals can't be stupid.

Still, this provides a reminder that the company's co-founder, John Harvey Kellogg, endorsed and promoted a radical, not-uncommon opinion for the late 19th century. From Kellogg's book, Plain Facts for Old and Young, here is Kellogg's "cure" for masturbation in children:

In younger children, with whom moral considerations will have no particular weight, other devices may be used. Bandaging the parts has been practiced with success. Tying the hands is also successful in some cases; but this will not always succeed, for they will often contrive to continue the habit in other ways, as by working the limbs, or lying upon the abdomen. Covering the organs with a cage has been practiced with entire success. A remedy which is almost always successful in small boys is circumcision, especially when there is any degree of phimosis. The operation should be performed by a surgeon without administering an anæsthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment, as it may well be in some cases. The soreness which continues for several weeks interrupts the practice, and if it had not previously become too firmly fixed, it may be forgotten and not resumed. If any attempt is made to watch the child, he should be so carefully surrounded by vigilance that he cannot possibly transgress without detection. If he is only partially watched, he soon learns to elude observation, and thus the effect is only to make him cunning in his vice.

This is one of the contributing arguments that encouraged the establishment of routine, medically unnecessary male circumcision in America. Anyone who denies this origin is misinformed when seeking a gender-based exception to the objective claim that medically unnecessary genital cutting on a non-consenting individual is unethical, whether the mutilated is female or male.

To demonstrate further, this is from Kellogg's writing:

In females, the author has found the application of pure carbolic acid to the clitoris an excellent means of allaying the abnormal excitement, and preventing the recurrence of the practice in those whose will power has become so weakened that the patient is unable to exercise entire self-control.

Victorian-era Americans embraced circumcision because they replaced priests with doctors. They did not replace superstition with science. American medical knowledge of the foreskin accepted a religious foundation for any research, just as American medical knowledge today is ignorant of the foreskin because the circumcised penis is viewed as normal rather than common.

While I think boycotting Kellogg in 2009 because John Harvey Kellogg was despicable in 1888 is melodramatic, the history is worth repeating independent of the company. Boycotting Kellogg in 2009 because of it's business decision regarding Mr. Phelps is a different matter. I support that.

January 31, 2009

Irrational Requests as Ethical Dilemma

Is it ethical to use fertility treatment when the mother already has six children?

How in the world does a woman with six children get a fertility doctor to help her have more _ eight more?

An ethical debate erupted Friday after it was learned that the Southern California woman who gave birth to octuplets this week had six children already.

Large multiple births "are presented on TV shows as a `Brady Bunch' moment. They're not," fumed Arthur Caplan, bioethics chairman at the University of Pennsylvania. He noted the serious and sometimes lethal complications and crushing medical costs that often come with high-multiple births.

So I don't use this solely to leapfrog to my concern, I'll say no, it's not ethical, although I won't go so far as to say it should be prohibited. But if the facts are as they're being speculated in the media, the doctor who administered these fertility treatments acted unethically.

Okay, so to jump to my question. We're talking about whether this is ethical, but not enough people would realize the ethical dilemma this presents for the law. This woman can legally alter the genitals of six of her newborns, for whatever reason or no reason, while her other two newborns are legally protected from unnecessary genital surgery. The general consensus in the American medical and legal community is that this is ethical. No one should be surprised that a ridiculous case of fertility treatment for a woman with six kids can occur.

January 28, 2009

AIDS relief does not redefine moral behavior.

Although I largely ignore Michael Gerson's columns because I know it's going to be feel-good, big government social conservatism, I will defend him on one point from his column today defending ousted PEPFAR coordinator Dr. Mark Dybul and condemning the method of his ouster. Primarily, Gerson states:

A few radical "reproductive rights" groups -- the fringe of a fringe -- accused Dybul of advocating "abstinence only" programs in AIDS prevention. It was always a lie. Dybul consistently supported comprehensive prevention efforts that include abstinence, faithfulness and condom use -- the approach that African governments themselves developed. ...

I conducted a quick search to find proof on what I know about PEPFAR and found this quote from the New York Times, from December 14, 2006:

[Dr. Dybul] also warned that it was only one new weapon in the fight, adding, ''Prevention efforts must reinforce the A.B.C. approach -- abstain, be faithful, and correct and consistent use of condoms.''

So Gerson's point that Dr Dybul is being unfairly attacked on these grounds is accurate.

However, the "it" Dr. Dybul refers derives from the previous paragraph in the New York Times story, an angle I knew I'd find in my research.

Dr. Mark Dybul, executive director of President Bush's $15 billion Emergency Plan for AIDS Relief, said in a statement that his agency ''will support implementation of safe medical male circumcision for H.I.V./AIDS prevention'' if world health agencies recommend it.

From PEPFAR's male circumcision brief, updated January 2009, here is a sample of PEPFAR's work:

In Zambia, PEPFAR continues to support a broad approach to prevention which includes male circumcision. Safe and effective medical male circumcision services are now provided at various sites to reduce new HIV infections and other sexually transmitted diseases. Working with the Ministry of Health, male circumcision is offered at the University Teaching Hospital in Lusaka and the General Hospital in Livingstone, as well as through satellite facilities. PEPFAR is also supporting training, public health evaluation on neonatal circumcision, and the development of comprehensive prevention messages to accompany medical male circumcision services. [emphasis added]

This is an action overseen by an individual Gerson describes as "a great humanitarian physician -- a man of faith and conscience". I have no reason to question the second claim, but one and three are demonstrably false.

I do not expect anything better from the Obama administration's eventual pick to replace Dr. Dybul. Always remember that when public health officials talk about voluntary, adult male circumcision, they never mean voluntary, adult. Never.

January 04, 2009

Female Rights Violations or Human Rights Violations?

Last Sunday, The Washington Post published a story about female genital mutilation in Kurdistan. The story is disturbing, as one should expect when dealing with FGM. The pictures - particularly number seven - show the violence involved. I'm going to let most of the story speak for itself, but I have a few comments on the larger topic.

.... In at least one Kurdish territory, 95 percent of women have undergone the practice, which human rights groups call female genital mutilation.

Any regular reader will know that I use the term "female genital mutilation". Rarely will I use any other, and then it's likely to be diminished only to "female genital cutting" if I reference a voluntary action an adult undertakes on her body. But many people incorrectly get caught up in the terms and miss the issue highlighted in the last sentence of that excerpt. Human rights are at stake. It's critical to describe our world as accurately as possible, but it is more important to prevent further violations. To the extent that focusing on terminology helps, let's focus on terminology. But where it prevents us from addressing the correct issue, we need to let it rest.

When I write about male circumcision, I generally prefer to label it "male genital mutilation", its more accurate term. However, I don't use that when I think it will distract from the core message. Being semantically correct helps move the discussion closer to the solution, but being stuck on semantics is stupid if I'm not connecting on the human rights issue.

The Kurdish region's minister of human rights, Yousif Mohammad Aziz, said he didn't think the issue required action by parliament. "Not every small problem in the community has to have a law dealing with it," he said.

This brings up the prominent argument too many libertarians deploy. (Read through the comments on the story at Hit & Run.) Notice the use of an adjective to dismiss the need to protect each individual. This is a common tactic among libertarians and non-libertarians alike. The speaker means to convert the subjective into an objective based solely on the his or her opinion. "Small" problem to whom? Clearly not the 7-year-old now-mutilated girl described in the article, Sheelan Anwar Omer.

But she became more animated when asked whether it was worth it to have the operation so her friends and neighbors would be comfortable eating food she prepared. "I would do anything not to have this pain, even if meant they would not eat from my hands," she rasped slowly.

"I just wish that I could be the way I was before the procedure," she said.

The issue is individual rights. All tastes and preferences are subjective, a core lesson a libertarian must understand. It is not enough to suggest that parents are acting in what they believe to be their child's best interests. Objective standards exist for evaluating parental behavior. The article describes an elderly (mutilated) women describing how genital mutilation makes a woman "spiritually clean so that others can eat the meals she prepares." Our ability to reason suggests that's ridiculous. In the unlikely event that it's true, it is subjective. Each individual should decide for herself.

The struggle against all genital mutilation, female and male, is primarily about the violation of forced cutting where no medical need exists for the victim's genitals. That's a basic human rights concept. It transcends nationality, culture, gender, and degree of harm. Either we defend the principle or we don't. A selective defense based on nationality, culture, gender, or degree of harm is also a selective endorsement of the underlying violation.

----------

From the article, a complication in the flawed "FGM is always perpetrated by men on women" argument:

... The circumcision is performed by women on women, and men are usually not involved in the procedure. In the case of Sheelan, her mother informed her father that she was going to have the circumcision performed, but otherwise, he played no role.

The article stated that one of the reasons it's performed is to control the female's sexuality. Of course. Arguing as I have in the past that FGM is not always performed for this reason is not a denial that control is the dominant excuse in most cases. I merely highlight this fact from the article because the issue is more complicated than what too many anti-FGM activists argue.

----------

From the blog entry at Hit & Run:

As readers of Ayaan Hirsi Ali's memoir, Infidel, can attest, among the most disturbing elements of such practices are the explicit urge to violently control female sexuality (even when the act is mostly symbolic, that's the function it performs) and the way it is enforced by other women. (Read Reason's interview with Hirsi Ali here). Say what you will about widespread male circumcision in the West (and elsewhere, for that matter), but it is not performed as a ritual of punishment defined to rigidify unequal standing in sexual, cultural, economic, and political matters.

I'm only arguing here against the violation of cutting a healthy individual without that individual's consent, not the physical damage caused or the excuses used to justify the violation. The violation is a universal principle. In that context, the argument in that paragraph - particularly its last sentence - is problematic factually and ethically, the latter being embraced with the myopic, haphazard application of individual rights too many libertarians use. (The entry's author, Nick Gillespie, doesn't exhibit that flaw here, in my opinion. But it is pervasive in the comments.)

Circumcision in America has been a tool to rigidify unequal standing in sexual matters, in males and females. (We could debate the other matters, but that's unnecessary here.) The surgery gained its acceptance in America - for male and female children - in the late 19th century as a tool to prevent masturbation. Regardless of how unsuccessful that's been, that is its origin, both medically and theologically. The lingering effect from that is essential to understanding the complete issue.

Then there are the parents who circumcise their sons because mom prefers circumcised partners. Would we accept fathers forcing breast implants on their daughters because dad likes large breasts? The revulsion at the mere hint is obvious. The conclusion with respect to male circumcision is also obvious.

There is little comparison in the degree of inequality typically imposed by male and female genital mutilation. I readily concede the point. But both involve placing the individual's desires below that of another who has physical power over him or her. That is the flaw, the violation of a universal human right.

For reference, Ms. Hirsi Ali states in this documentary that male circumcision is genital mutilation. Again, I'm not equating the typical degree of mutilation. They are different. But the core issue is the violation. That is the same. It's possible to focus on FGM without minimizing MGM.

November 24, 2008

The Ethics of Vanity, Part III

Even though blogging has been sporadic recently, I'm paying attention. I realize I've given far more attention to circumcision than any other topic lately. Rolling Doughnut is not turning in to "all circumcision, all the time," I swear. But the backlog is there right now. So, a little bit more, and then other stuff will return.

Last week I saw news links similar to this article.

It sounds like just another uber-meltable cheese product, but Vavelta is actually miles away from anything you'd want to put in your mouth. It's a radical new treatment for facial pitting, scarring, and wrinkles made out of—what else?—newborns' foreskins.

I didn't write about it because it's just a new example of something I've discussed before. And, while I'm happy an ethical issue appeared in the article...

There are also ethical issues to consider, especially if the folks behind Vavelta start paying parents for their sons' severed sheaths.

... it hints at the wrong ethical issue. Parents do not own their sons' foreskins. That's why they don't have the right to cut them off, much less demand payment for them. If a similar value worked for freshly circumcised adult foreskins, adult males should be free to sell for the highest price. They're not, because the state thinks selling parts of your body is "wrong". But taking healthy, functioning body parts from a child for no objective reason without his consent? That's somehow a valid parental choice. It's madness.

----------

The link came from Hit & Run where I expected to encounter juvenile nonsense, the normal trend of comments there. To my surprise, my fellow libertarians came through in shining glory. Before that, this from commenter Dello:

f I had male children, they'd all get the cut. In the end (of life, that is), it's for their own good.

This is the dumbest excuse I've encountered, although this is not the first time. Dello explains further:

....wait until you're 75, incapacitated, and in a nursing home. Since none of the aides will wash your genitals, having a foreskin means you won't even get fresh water around the head of your penis.

It had to get worse before it got better. The good stuff, from SugarFree:

Yes. Mutilate your penis because you might end up in a crooked rest home. There's a winning argument.

Right. Except, it needs a clarification, provided by Episiarch:

NutraSweet, you have it wrong. It's mutilate your son's penis because he might end up in a crooked rest home. That's even more full of ethical win.

Bingo. Really, how hard is it to understand that most adult males will not end up debilitated in a nursing home that won't care for them properly. Anyway, if it's causing problems at 75, that's a medical necessity. Circumcise then. This is not complicated.

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Naturally, someone had to begin the path to logic with an unquestioned regurgitation of simplistic propaganda, as if this dismisses ethical concerns. From J sub D:

A serious note -

Circumcision Gives Men up to 60% HIV Protection; WHO, UNAIDS Urge Adult Surgery

First, condoms. This is not complicated. They're more effective and cheaper. Second, what part of urge adult surgery involves newborn foreskins? The studies used adult volunteers, not infants who can't consent.

Denmark proposes equal rights.

[Update: I've fixed grammar in the opening sentence. Also, the comments provide a critique and clarification on my point about Islam as it may or may not relate to this proposal.]

I suspect Danish politicians are proposing a ban on male child circumcision because it's an accepted part of Islam. That's the wrong approach, since individual rights achieve the same results without intentionally creating hostility to faith. As long as sanity prevails in the (potential) implementation, the risk is small.

For a thread of comments on this topic, I spent part of my weekend commenting at Amy Alkon's Advice Goddess Blog. I can't say I'm surprised by what's been written there, but Ms. Alkon and a few commenters have been logical and accurate in assessing the issue. I recommend the thread because there are many examples of the thought processes leading to infant circumcision that I've written about.

----------

About the proposed protection of children itself, it would apply to males under the age of 15, the age of majority for bodily decisions in Denmark. It's entirely sensible and consistent with principles of liberty. Naturally, some people oppose it.

While the Social Democrats, Red-Green Alliance and Liberal Alliance have come out in support of a ban, the Danish People's Party called it 'tyranny'.

'It's completely ridiculous to compare the circumcision of girls - which is a barbaric mutilation - with that of boys, where it's just the removal of a skin flap,' said the party's Jesper Langballe.

I don't expect much from any group "People's Party", and this doesn't disappoint. Unfortunately. Ethically, male and female genital mutilation are the same violation. But the issue always gets stuck at the physical results. Anyone who thinks that all FGM is the most extreme version is uninformed, especially if that person doesn't recognize that anti-FGM laws make no such distinctions about results. (Again, correctly, as I've stated many times.) Anyone who thinks that the foreskin is just a "skin flap" is also uninformed. Langballe achieves a perfect score, I suppose.

Yet, the Danish People's Party's health spokewoman, Liselott Brixt, gets it right.

'A lot of parents want it done to their children because they themselves had it done. But we're living in the present and it isn't fair to expose healthy children to religious circumcision.'

Healthy children is a reasoned fact. Religious adherence requires faith. One need not reject faith to recognize that it is not a reasoned approach to medical intervention. The latter must prevail because human rights belong to the individual.

November 17, 2008

Ethics does not require medicine. Medicine requires ethics.

I finally figured out how to explain the flaw in the thinking I challenged last week, the flaw that believes male and female genital mutilation are not morally equivalent. The path to missing the truth is clear. The blogger who claimed that gender is a valid surgical distinction assigned his entry to a category - "Medicine" - that misses the point. It's a category that he would explicitly refuse to assign any discussion of female genital mutilation. He would file any such post to "Ethics". That's where he should've posted Wednesday's entry.

In his mind, and in every encounter I've had on this topic, the assumption informing the lapse in reason always rests on the mistaken notion that the claimed potential benefits from male genital mutilation inform the ethics of imposing the procedure on another. It can be helpful, so it is acceptable. Obviously it's desirable for the patient. Obviously. Also obvious, because it's now acceptable and presumptively desirable, it must be desired by the patient. We assume that every male who can't consent would consent if given the option, so there's no need to bother with waiting. Waiting only increases the likelihood that one of the scary possibilities from being intact will affect the male.

But that misses the subjectivity of potential benefits and the evaluation each individual might undertake if he retains his normal choices. There is no medical need at the imposition of the surgery. Ethics must dictate a refusal to impose unnecessary surgical procedures, which is most often nothing more than tradition and conformity masquerading as medicine. The key word is impose. That requires legitimate ethical consideration, a test that cultural and ritual male child genital mutilation fail.

With female genital mutilation, our society recognizes no potential medical benefits. We do not consider the silly idea of chasing any. We assume no benefit and understand the obvious harm. We invoke only ethics, rejecting any hypothetical encroachment of speculative, preventive medicine into the ethics. Everyone in western society accepts that it is morally objectionable to impose unnecessary genital modification on a healthy individual who can't consent, if the healthy individual is female. We know females would not consent to genital modification. Yet, we have evidence that seems to contradict this in societies that practice FGM. In the United States some adult females willingly choose cosmetic surgical alteration of their genitals. We refuse to accept the former and willfully ignore the latter.

This adherence to a gender-based relativism is the ethical myopia that leads to the mistaken belief that male and female genital mutilation are not the same immoral human rights violation. They are morally indistinguishable because humans possess human rights, not just female humans. Society errs every time it sanctions parents imposing surgical genital modification on their healthy child. We've reasoned our way to the proper understanding of female genital mutilation. We need to stop rejecting reason the same proper understanding of male genital mutilation.

November 13, 2008

Morality: Gender and Violence

I want to add a thought to last night's post on whether or not male genital mutilation is morally equivalent to female genital mutilation. (It is.)

Is domestic violence perpetrated by a woman against a man morally equivalent to domestic violence perpetrated by a man against a woman?

The latter occurs far more frequently. Men are generally stronger than women. These do not matter in judging the immorality of the violence because the attack violates the individual. The outcome informs the decision on punishment, but it does not change the original fact that a crime occurred.

What's the difference with male genital mutilation, if not gender and tradition? Neither are effective counter-arguments against facts and individual - human, not just female - rights. Each person owns his or her body from birth. We must permit proxy consent to maximize liberty. Liberty isn't much good if the child dies. But the possibility of future medical problems is not the existence of a medical problem warranting the exercise of proxy consent to surgical intervention.

Any claim that current and future religious/cultural problems may result from normal human genitalia fails the test for permitting the exercise of proxy consent to surgical intervention. Fails it miserably.

Low Nutritional Value Politics

Last week I saw both of these Tom Toles editorial cartoons, but never together.

Toles_11052008.gif

And:

Toles_11072008.gif

The second cartoon, from Friday, is much more effective because it's correct. The first cartoon, from Tuesday, is full of sentimentality but devoid of truth. (To be fair, we moved closer to truth, although not as much as everyone believes.) The success of California's Proposition 8 demonstrated that "All men are created equal" isn't fully realized yet. Maybe it will never be. And there are many issues where our society falls short of the ideal. Denying those because we want some warm, fuzzy feelings for a day is unproductive.

November 12, 2008

Theft is theft.

A post at denialism blog claims that male and female genital mutilation are not morally equivalent. After some buildup, the gist of the entry:

Independent of how you may feel about male circumcision, it does not normally, or even more than very rarely, lead to long-term medical consequences. FGM nearly always does. FGM is not usually as "simple" as a pinprick. And who performs it is irrelevant. If women are co-opted into torturing each other by the dominant male culture, that is most emphatically not a mitigating factor, but a sign of how deeply disturbed gender relations in the culture are.

There are many long-term medical consequences that are discounted or ignored. Scarring is a long-term (permanent) consequence. An asymmetrical incision is a long-term consequence. But those are not what the author implies, so I'll consider it on his strict terms that those should be ignored. Would the removal of too much skin constitute a long-term medical consequence, since it leads to painful erections? Or are we just considering a negative result such as loss of the glans and other extreme outcomes?

Regardless of the answer, the ethical question looms larger. Who decides which medical consequences matter? Risk aversion and personal preferences are subjective to the individual. If the decision-maker is someone other than the individual whose body is altered, the intervention must be medically necessary. Otherwise, the surgery is immoral. Gender is irrelevant.

Notice, too, how the margins are ignored. Some male genital modification results in devastating consequences. Some female genital modification is physically insignificant. Those cannot be tossed aside as irrelevant. They inform the discussion. Why is it that the latter is legally prohibited under all non-medical circumstances, yet the former is considered an acceptable risk in the same non-medical circumstances? We do not get to dismiss inconvenient details.

The last part about who performs the mutilation flows into the author's next paragraph, which I'll break into segments:

Male circ is not a method of controlling males and their sexuality.

This is incorrect. Genital mutilation - of males and females - began in America as a method to prevent masturbation, among many grand claims by its advocates. Today we have the constant defense of the practice for males¹ based on a reduced risk of female-to-male transmission of HIV. What is the justification for modifying the genitals of infant males if it is not an attempt to control their sexuality? The undeniable assumption is that they will not be competent enough to practice safe sex. Remember that the studies from Africa involved only voluntary, adult circumcision. Transferring such findings to infants requires assumptions.

Also consider two very common defenses given for mutilating infant boys in America. Proponents claim that circumcised men take longer to orgasm than intact men. First, consider what that suggests about the long-term consequences on male sensation from the foreskin and the loss of the foreskin. Although I am not making the claim here that this is true, advocates of circumcision always deny this logical conclusion. But it is very clearly meant as the preferred expression of male sexuality. And it is most often imposed on infants. Second, the assumption is that he wouldn't last long enough, however long that might be, without the removal of his foreskin. Another decides for him. I refuse to redefine the concept of control.

The other common claim is that women prefer the circumcised penis. A male's future partner's assumed preference matters exclusively, even though he may prefer to be intact and might choose to reject any woman who would reject him for having the body he was born with. Think of the corrollary. If men prefer large breasts and we forced breast implants on females, would we view that as an attempt to control female sexuality? What is this, if not control?

Continuing:

In nearly every culture that has ever existed (and one might argue that this is even more true of cultures that circumcise), males are dominant. FGM is always---always---a method of controlling women and their sexuality.

If we're establishing that societal attempts to control an individual's sexuality through surgical alteration is immoral, and we are, then we're done. We can wrap potential benefits around the procedure for males, but it is not the least invasive option for any of its claimed benefits. The conclusion is the same. The surgical alteration of a healthy, non-consenting individual's genitals is immoral. Gender is irrelevant to the fundamental moral claim. The extent of the damage is irrelevant to the fundamental moral claim. We may decide that legal punishment should differ based on actual results (including the uncommon extremes for each, which means minimal punishment for lesser forms of FGM), but the act itself is immoral. Every victim - female or male - is a victim.

For a similar analysis applied to religious male genital mutilation, see this entry from my archives.

November 04, 2008

Adjective-filled headlines aren't objective reporting.

I wish I could send a memo to every newspaper headline writer. It would be brief, saying only "This headline is not clever."

The kindest cut — AIDS-ravaged Swaziland rolls out male circumcision to prevent AIDS

First, notice how - once again - voluntary and adult are left out of the headline. The studies in Africa that have caused the world to lose its capacity to think rationally researched voluntary, adult male circumcision, not forced circumcision of boys. That's an entirely different study, with impossible-to-overcome ethical hurdles.

Next, most dangerous complaint: the studies did not find that male circumcision prevents HIV infection. They concluded that male circumcision reduces the (short-term) risk of becoming HIV-infected. There is a significant difference, clearly lost in the current marketing. Somehow the correct interpretation appears in the story. I suppose the truth isn't sexy enough for the headline. Marketing, folks, marketing.

Finally, regarding male circumcision being "the kindest cut", the implication clearly implies that it's kind on the part of the cutter. Shouldn't the concern be for what and why the individual chooses for himself? For the cutter, it's should be nothing but an objective medical procedure. Hacking away at the body of another for your reasons is unreasonable.

I allegedly have a reduced risk of being infected with HIV through sexual intercourse. I don't engage in risky behavior, so my risk is zero. I do not care about any potential HIV risk reduction. For that reason, and many others, I do not consider my circumcision to be "kind". It's the rudest, most inhumane act as yet committed against me. My opinion is all that matters.

Or, all that should've mattered.

October 17, 2008

Finland should legalize honor killings, too, since the individual doesn't matter.

I don't know the intricacies of Finnish law. I don't need to know them to know that this is obscene.

A circumcision performed on a Muslim boy in Finland was not a penal offence, Finland's Supreme Court (KKO) decided Friday in a precedent setting case.
...

However, according to the Supreme Court a circumcision done for religious reasons helped the son in the development of his identity. The operation also helped him to become attached to his religious and social community.

How does the court know it helped him in his identity? What they mean is that they assume it will help him develop his identity as a Muslim because Muslim's circumcise. That is an appeal to subjugating the individual to the group. It is anti-liberty. At some point, preferably sooner, tradition must be analyzed for what it is, not how long it has been around, or which non-legally-binding books demand it.

It gets much, much worse:

The court decided that the child's parent was allowed to decide on the operation as it was not against the interests of the child. The boy's bodily integrity was violated only a little and as the operation was conducted under local anaesthetic, it did not cause the child unnecessary suffering.

Why not say it's okay to rape women, as long as the rapist wears a condom? I mean, it's not like he'll get her pregnant or give her a disease. It only violates her bodily integrity a little. Some counseling, a bit of time, and voila, the problem disappears.

Just like circumcision only removes a few thousand nerve endings and some tissue. So what if he's healthy and surgery imposes objective risks. He¹ will be thankful, as long as his parents' subjective opinion demands it. It's minor, really. It's not for the individual to complain. It's merely his body, and what is that, really?

The only valid precedent set by the Finnish Supreme Court is that its judges are insane anti-liberty cretins. Demonstrated by Finland's existing prohibition on female genital mutilation, they're also disgusting hypocrites.

¹ Or she? Her opinion is also irrelevant, subject to whatever whim her parents hold, right?

October 10, 2008

No conspiracy. I think the media is lazy.

Here are three stories to demonstrate that media reporting on male circumcision borders on propaganda. First, from Aidsmap:

A meta-analysis of studies of circumcision in gay men and men who have sex with men (MSM) has not found sufficient evidence to show that being circumcised reduced their risk of acquiring HIV. Although it finds a small reduction in the risk of HIV infection in circumcised men, this is not statistically significant - in other words it could just be a chance finding. Furthermore, the study, published in the Journal of the American Medical Association, found that although circumcised men who were exclusively insertive for anal sex had a lower risk of infection with HIV, the difference with uncircumcised men was still not statistically significant and could have been chance.

Fair enough, and there are further possibly-relevant nuances in the article. Those aren't my focus here (nor do they overcome my principled objection to forced circumcision). Rather, consider how the editor titled this news:

Jury still out on whether circumcision protects gay men against HIV

What would it take for the jury to finally be in? We see how quickly it's in on unstudied results assumed from a study that appears to give the results the researcher wants. (The answer? Six days.) When the jury gives an answer you don't like? Deliberate further. I don't wonder why.

Note: We can debate the semantics of scientific investigation of the hypothesis and findings, but pro-circumcision researchers use only a very loose application of either.

Second, from Time (emphasis added):

Circumcision is believed to lower H.I.V. transmission in several ways. The inner surface of the foreskin is rich with cells that are more vulnerable to H.I.V. than cells on other parts of the penis; because they are also closer to the epithelial surface and at higher risk for tears during intercourse, they increase susceptibility to infection. Removal of the foreskin further lowers men's odds of developing genital ulcers (from diseases such as syphilis), which in turn lowers their vulnerability to H.I.V. during intercourse. In theory, circumcision should be protective for all men who participate in insertive sex, including heterosexual men and men who have sex with men.

Believed to lower is accurate, because all studies involving (voluntary, adult!) male circumcision and HIV risk reduction look at results. None of them have shown what generates the results researchers claim. There are theories, but nothing concrete. It could be nothing more than flawed methodology, right? Yet, Time reported male circumcision's claimed role in reducing HIV risk as its 2007 medical breakthrough of the year. Has the magazine changed its opinion to one of logically-defensible caution?

Third, from the Jerusalem Post:

Almost a third of male immigrants from the former Soviet Union are uncircumcised, according to a survey by the Geocartography Institute commissioned by the Jerusalem AIDS Project.
...

The survey also found that 2.2% of women who immigrated from the FSU "didn't know" whether their partner was circumcised, and 72.8% of female partners of uncircumcised new immigrants would prefer that they don't undergo ritual circumcision.

That 72.8% figure is interesting. It's subjective, a point I actively make, even when it benefits me. But this is the type of irrelevant statistic pro-circumcision propagandists like Dr. Brian Morris love to spew when their carefully-chosen studies suggest that women prefer circumcised partners. We mark anyone who would argue in favor of compulsory breast implants for teen girls because their male partners prefer large breasts as intellectually ridiculous. The same applies here. What women prefer only matters if the male choosing circumcision for himself wants it to influence his decision. For the anti-intellectuals who don't get this, the propaganda can work against them. They'll never notice, of course.

Continuing, with emphasis added:

Research carried out abroad shows incontrovertibly that circumcision reduces by 60% the risk of a man being infected with HIV by a female carrier. In many African countries with high HIV rates, men are lining up for circumcision, and Israel's experience in circumcising thousands of adult males has aroused interest in the UN and among African governments.

How does incontrovertibly reconcile with believed to lower? In the same way that "six in 10 circumcised men are immune to HIV infection"?

October 07, 2008

Always check your assumptions.

I'm always curious to see how our biases encourage us to frame reality. It can be something as simple and unimportant as complaining that the umpire squeezed the strike zone on your team's starting pitcher instead of admitting that each pitch consistently passed the plate over the batter's box. Or it can be something more, as this entry demonstrates in referencing the U.S. Supreme Court's refusal to hear the Oregon circumcision case, which I mentioned yesterday.

UPDATE - My good friend Rabbi Zalman Berkowitz at miyan this morning reminded me that a conversion is in almost all cases not complete without the bris. In other words, the Supreme Court is preventing the kid from his religious aspirations by not ruling in favor of the father. It is not going too far out on a limb to come to the conclusion that this case prevents freedom of religion, and is an invasion of privacy. The case now goes back to an Oregon judge to determine whether the boy wants to undergo the procedure.

That's an interesting way of analyzing the Court's decision that is self-evidently wrong. The blogger assumes that the boy wishes to convert and have himself circumcised. The Oregon Supreme Court concluded that it did not know the answer to that question, only the stated claims of the father (for) and mother (against). The Supreme Court is merely saying that procedural paths short of its consideration have not been exhausted. The Court did not close the option for the boy to undergo circumcision if he indeed wishes to convert and undergo circumcision. But assuming the boy wants the circumcision is (at least) one assumption too many.

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It's worth remembering that the Oregon Supreme Court established two tests for the lower court to use in its evaluation. If the boy wants circumcision, the case is over. Fair enough, you will hear no complaints from me. His body, his choice.

But if the boy does not want circumcision, the case continues, with the lower court instructed to determine if the father's imposition of circumcision would cause irreparable harm to his relationship with his son. The court essentially ignored that this would be the imposition of medically unnecessary genital surgery on an individual who objectively denies consent. One person is granted property rights over another if the court rules using a subjective test. Apart from being ethically wrong, that is hardly a precedent for arguing that the state is preventing freedom of religion.

This is also a good time to again state my position on ritual child circumcision. The problem with ritual child circumcision is not its religious aspect. The age - and by extension, ability to consent - of the circumcised is the sole issue. The child can't consent. He might not consent when he can decide for himself. The surgery under consideration is not medically indicated, making this solely an issue of self-ownership. Each person has an exclusive liberty interest in his (or her) body. No one has an option for proxy consent that can ever legitimately overcome this natural right. Claiming a First Amendment protection is no help because the child retains his right to - and from - religion, independent of his parents' opinion. Government also has a legitimate interest in preventing the imposition of objectively identifiable physical harm on another who can't consent.

I've written in the past that the age of majority should be the legal standard for non-medically-indicated surgery. However, I am not opposed to a competent minor deciding for himself that he wants to be circumcised, for whatever reason he prefers. A 12- or 13-year-old may have developed sufficient maturity to decide this for himself. Perhaps the child in this case fits that, and if so, again, you will hear no complaint from me about his decision or his father's willingness to grant that request.

Disclosure: I would not consent to the procedure if my (hypothetical,) healthy 13-year-old son asked to be circumcised, if that matters in considering my analysis. Saying "no" to a child's wish for non-medically-indicated surgery is a legitimate parenting choice. Saying "yes" over a child's objection is not. The former is a temporary denial of a liberty interest based on the parents' subjective judgment. The latter is a permanent denial of a liberty interest based on the parents' subjective judgment. The subjectivity of parental judgment is the crux of this case, as well as the general topic of child circumcision.

October 06, 2008

The activist judges in Washington are not active.

Here's an update to the ongoing circumcision case in Orgeon, confirming my expectation from May:

The U.S. Supreme Court has rejected an Oregon dispute between a father who wants to circumcise his 13-year-old son against the wishes of the boy's mother.

The case now goes back to an Oregon trial judge to determine whether the boy wants to undergo the procedure.

Of course. I'm not an attorney like the father, but even I could figure out that the Supreme Court would refrain from addressing the issue because the lesser options to resolve the case haven't been exhausted. This is the correct course of non-action.

From a different angle, it will be wonderful when sentence two in the news report is not relegated to an afterthought. It's the question that matters.

October 05, 2008

I've been thinking.

Hi, I run an active blog here. You may not know it because the top of the main page changes so rarely these days. There are now only 5 posts, including this one, on the 21-day-history main page. But I'm still here, still pondering the world and figuring out what to say about it. Normally that's easy: read news, sit in front of computer, type, publish. Easy.

Yeah, I wish. Really, it takes motivation and creativity. I've had little of the former lately and the latter takes effort. I'm to blame.

More interesting - hopefully - is the reason behind the lull. I didn't know what it was. I just knew that diverted attention left this page stale. The Phillies are still in the playoffs and winning. That takes some. I've also rediscovered my Xbox 360, only to get the Red Ring of Death. And so on.

That was my explanation until Friday night. Driving home, I listened to music rather than talk radio or podcasts. Time to not think actively freed me to figure out my the explanation. Apathy. I've been at this long enough to realize how consistent the themes are. Too few care much about liberty, choosing instead to structure the world according to their own lives.

Ranting here about the bailout bill, for example, would accomplish so little. The narrative is set. Morons like Harold Meyerson rule the day. It won't last forever, but while it does, the anti-intellectuals won't be stopped. I did not favor the bailout, nor do I favor the corporate welfare so many misinterpret as free market capitalism. The story will remain free of facts as long as there is an outcome-determined agenda. The socialist is no different than the corporatist.

I won't change the world. So what? I don't write to change the world. I write because I like it. It helps me process the world. It helps me learn. It helps me teach. And I'd rather focus on individuals. If I convince one person to refrain from circumcising a child, it's worth it. If I provide an insight that helps someone convince someone else, it's worth it. I won't change the world. So what.

In other words, I'm back. The pace probably won't pick up immediately. The Phillies are still in the playoffs, remember. But I've decided to stop being angry that people continue to harm others, be it with the state or the scalpel. I'll write instead. And I'll get angry again. I'll just direct it rather than allow it to fester.

Pathetic? Meh.

September 23, 2008

Age Discrimination: Patient and Doctor Edition

Here's a story that taps my two main interests:

A MEMBER of the Bagisu Cultural Board has proposed that the retirement age for the circumcision surgeons (Bakhebi) be set at 60 years if their sight is still good.

He said this would minimise the accidents that occur during the operation. John Musila made the remarks at a consultative workshop on the promotion of safe male circumcision in the era of HIV/AIDS, held at Communications Centre hall in Mbale town on Saturday.

I'll take the paragraphs in reverse order. As for reducing accidents during circumcision, clearly not performing circumcisions would be most effective. Again, I do not care what an adult chooses for himself (or herself). But that's not what we're ultimately discussing with this story. When introducing the HIV topic, we inevitably move from voluntary, adult circumcision to involuntary, child circumcision. Making the latter safer is better, but it is barely an ethical improvement.

Now I'll assume only that we're talking about voluntary, adult circumcision. In considering the libertarian implication of the age restriction, I'll also assume the legitimacy of the state licensing the medical profession¹. Obviously it's irrational to have a blind doctor. But what does age have to do with it? A 30-year-old doctor can go blind and a 75-year-old doctor can retain all of her capabilities. The test is competence, not arbitrary lines the may or may not lead us to a good result most of the time.

This is similar to suggesting that we must prohibit medically unnecessary circumcision, unless it's imposed on children to meet their parents' religion. There is no principle involved. In the scenario in the story, if the doctor is competent, no needless limits should be placed on him to prevent him from engaging in his profession. He must be free to trade his services to a willing customer.

¹ My default position on this low-priority issue is an endorsement of something close to our status quo.

September 11, 2008

Government can and will break its own rules.

When I say that the introduction of single-payer healthcare would not lead to the en - or even a significant reduction in - the circumcision of infant males in the United States, I do not hope I'm right. But I still see no reason to think I'm wrong. My analysis includes the evidence that countries with nationalized healthcare don't pay for ritual/cultural circumcision. I also understand that claiming any particular market is somehow different is dangerous. But it's quite clear that Americans have an irrational affinity for cutting the genitals of male children. That is a political rather than economic factor in this debate. Our politicians have never shown an ability to say "no" when confronted with a choice of excessive spending or the potential loss of votes. Wrap in religion and it's a perfect combination for everyone to ignore facts (and the child).

There is one fact in the above narrative that is not accurate. If you've guessed that countries with nationalized healhtcare pay for ritual circumcision, congratulations, you understand politics at the expense of economics. From England:

... medical opinion has swung against it, and the procedure is now mainly carried out here for religious reasons.

As such, according to NHS guidelines, it should only be carried out, and paid for, privately.

But an investigation by More4 News has found an increasing number of health trusts are bowing to pressure, and offering circumcisions free on the NHS.

I'd normally embed the video here. I do not like the still image presented before the video plays. You can find it at the link above, or directly here.

Take note that no one in the report mentions what the boys might want. It's a religious requirement for the parents to impose on their children. That's enough for everyone to ignore the obvious questions beyond the cost, even though unnecessary circumcision is unjust, both morally and legally. But even in a culture like England that generally does not circumcise, mix the parents' religion with an inability to pay and the state pays. America will be different how?

The bit about "unscrupulous circumcision practitioners" is particularly fascinating. The doctor interviewed in the beginning of the report operates in a glass house. No, he's not a mechanic circumcising an infant with a soldering iron. Yet, he is a professional sworn to an oath placing the patient's health as his first priority. As long as his child patients are healthy when he mutilates them, he is nothing more than an unscrupulous circumcision practitioner with training. The physical results may be less troublesome, but those children will still carry the mark of his criminal lack of ethics for the rest of their lives.

Post Script: I still detest the idea of single-payer healthcare because of the inevitable deterioration in health and care before we get to any discussion of rights.

August 28, 2008

When is a poor tactic a crime?

I'm curious about the facts behind this arrest, because I can assume several different scenarios:

On 8/26/08 at 6:50 p.m., Victoria Marmontello, 37, of 4224 Aurora Path, Liverpool, NY, was arrested for Endangering the Welfare of a Child, a class A misdemeanor. Released on an appearance ticket, Ms. Marmontello is scheduled to answer the charge before Town of Parish Court on 9/09/08. She is accused of talking about sex and circumcision to minors on 8/07/08 and demonstrating what a circumcision looked like by showing the circumcised penis of another minor to the children while at a campsite located in the Town of Parish.

Hmmmm, what to make of this? There are necessary details missing from this report to get an accurate understanding, so I'll fill those with assumptions. I'll try to make those clear while speculating with my experience-influenced guess.

Probably the problem with talking about sex and circumcision to minors is more problematic to prosecutors because of the sex, not the circumcision. When I speak to minors, I keep the emphasis on circumcision because the kids don't need discussion of sex to grok the angle I take. Sure there are sexual consequences, objective and subjective. Those aren't necessary. Children have rights, and their healthy bodies don't need surgery. Minors of a reasonable age - teen-ish? - will make the connection based on their own knowledge, so I leave it out until they ask questions. And, while I find it hard to pass judgment on discussing sex with minors without the specifics of this case, I err to more knowledge is better than less knowledge. If the allegation is factually correct, I doubt Ms. Marmontello used tawdry terms intending to titillate.

More likely the problem on this point was teaching children about circumcision. I've witnessed parents and chaperons pull children away after realizing that the protest they've stumbled upon is not "innocent". I've heard the comments, usually some variation on "it's your parents' right to decide and they do it when you're a baby". The objection is always about the adults trying to continue their own willful ignorance and forcing the same on their children. Educate children properly and they tend to question. Parents who circumcise don't like that. If our protests weren't at the steps of the Capitol, with police support, I suspect some parents would challenge our rights with a bit more vigor.

None of that is to suggest it's impossible to cross a line when discussing circumcision with minors. It is. But there needs to be more than being factual and anatomically correct.

The thornier question is the latter charge. Again, there are relevant facts left out here. "Showing the circumcised penis of another minor" is not enough to know what happened. I suspect she showed a picture rather than had a boy drop his pants. That's what I'll assume. Such pictures are certainly widely available on the Internet, many of them in the context of the numerous possible complications from circumcision. I don't use them for the same reason I think anti-abortion advocates are stupid to throw around pictures of aborted fetuses. It's counter-productive. And with children other than your own, it's especially stupid. Probably more stupid than showing them pictures of a circumcised adult penis because of the obvious child porn implications.

In agitating against forced circumcision, it's painfully clear that our society is insane about anything related to sex. Medicalized unnecessary genital cutting - male and female - began in America as a solution for masturbation. As much as it's undeniable that I am not the one with flawed thinking on this topic, dancing around society's insanity is just smart strategy. We can and must address it, but trampling on it is dumb. It's possible to teach about circumcision with nearly the same efficacy with a long sleeve shirt.

To be clear, I'm not endorsing Ms. Marmontello's alleged actions. I've assumed the most innocent explanation for the latter charge. There could be more. If there isn't, I don't think that scenario should be a crime. Thoughts?

Post Script: I made it all the way to here without making a remark about circumcision endangering the welfare of a child. So there it is. Cutting your male child's healthy genitals: not a crime. Someone explaining to your children about cutting your male child's healthy genitals: a crime. Yeah, that makes sense.

August 22, 2008

State property or parental property is still property.

In the sense that the term is used to imply a moral obligation and chosen desire to provide and care for children, I have no objections to discussing parental rights. To some extent that's what I read as the goal in this editorial by Thomas Bowden of the Ayn Rand Center for Individual Rights. I just wish the correct use was the basis of the discussion rather than the caveat. Mr. Bowden introduces the topic in response to the recent ruling in California affirming the legality of homeschooling.

But where’s the real victory for parents’ rights? Rights identify actions you can take without permission. A true victory would have been a judicial declaration that parents have an absolute right to control their children’s upbringing--and that they therefore don’t need government permission to educate their children as they see fit.

There's much more verbiage in the essay taking that same lazy approach. But absolute should not be accepted as a stand-in for nuance. Is this particularly libertarian?

To give parents a permanent victory, California would need to make its law consistent with America’s founding principles. Parents are sovereign individuals whose right to life, liberty, and the pursuit of happiness includes the right to control their child’s upbringing. Other citizens, however numerous or politically powerful, have no moral right to substitute their views on child-raising for those of the father and mother who created that child.

We know that rights are ignored far too often, but that doesn't provide us justification to fling the word about as if expanding its definition and application are all that matter. That justification doesn't exist, nor is that approach to rights correct. Where the individual is concerned, yes, but children are also individuals. Sharing DNA is not a contract capable of converting an obligation into a right. Creating the child is the parents' right as individuals. Raising that child is better approached as an obligation with important qualifications. (I use obligation as an objective term not meant to imply a burden.)

Mr. Bowden gets closer later in his essay:

Of course, there are certain situations in which government must step in to protect the rights of a child, as in cases of physical abuse or neglect. ...

Education, like nutrition, should be recognized as the exclusive domain of a child’s parents, within legal limits objectively defining child abuse and neglect. ...

The qualification is key to advancing liberty first, for each individual. How best to do that, and on which principles, is next. Parents are the correct answer. But setting limits using objective standards should never be lost in the issue. Parents must be free to homeschool their children because they are best positioned to respond to the child's positive right to an education. That is not a concession that the child may be held in a perpetual state of ignorance that will inhibit or prevent her from becoming a functioning, independent adult. Bowden succeeds where he makes that point. I wish he'd gotten there earlier so he'd have more time to defend this proper view of liberty instead of retreating on exaggerated claims.

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For discussion: How likely is it that children will respect liberty when they become adults if they're only granted their basic, fundamental liberties at the discretion of their parents? Where liberty is denied, is it really better if parents deny it rather than the state?

August 15, 2008

Let's ramble together.

It's been too many days. Blah, work, blah. More on this sometime this weekend. Moving on.

Many, many circumcision stories have popped through lately. I'm aiming for a quick hit to clear them out. First up:

“In our study we found gay men who were circumcised at infancy didn’t report having some kind of negative or positive impact on sexual dysfunction.

“However, nearly all men who were circumcised after infancy reported some sexual dysfunction, erectile problems or premature ejaculation, and one in five reported some complication as a result of the circumcision. ..."

We all see the obvious flaw, I think. Didn't report. Is it too difficult to extrapolate that self-reporting is subjective, and therefore inferior, to objective considerations. How about I theorize that all circumcision results in some form and degree of sexual dysfunction. Those circumcised at infancy just don't realize it. I can't (and won't) say that's true, but it's no worse than the above.

Next, there was an international conference on HIV/AIDS in Mexico City recently. Of course all discussion of circumcision seemed to focus entirely on the allegedly miraculous power of circumcision. I encountered very little consideration of ethics. I found an example of this indifference in the New York Times, which is almost always reliably bad in this respect.

There was no question about the ethical need for an early stop of the trials. ...

But there was a question about the ethical need to constrain the implementation of voluntary, adult circumcision to adults volunteering to undergo circumcision. Public health officials ignored that ethical need within six days. They've continued to ignore it since.

For example, in an article titled "Not such an unkind cut, after all":

Modern techniques make the risks associated with circumcisions insignificant.

Insignificant according to whom? Not necessarily the person facing those risks, yet that gets ignored in favor of propaganda.

Brisbane doctor Terry Russell, who has performed about 19,000 circumcisions, says he has never had a case in which a blood transfusion was required, or a systemic infection ensued. "We see minor local infection in about 2 per cent of the boys that we do, but most are treated without putting them on antibiotics."

Russell uses the PlastiBell for his procedures, which is a small ring that fits inside the foreskin, over the head of the penis. The foreskin is compressed between the ring on the inside, and a string which is tied to the outside of the foreskin. The clamping cuts off circulation in the area, reducing the risk of bleeding and infection. The PlastiBell accurately defines how much foreskin should be removed, "so you can't take off too much or too little", says Russell.

Too much or too little according to whom? Not necessarily the person losing the (functioning, healthy) foreskin, yet that gets ignored in favor of propaganda. And where there's propaganda, we can almost always find one of our cadre of propagandists. This time, it's Brian Morris:

An unequivocal advocate of circumcision, Morris notes that men who have the procedure enjoy better hygiene."Just general, day-to-day, run-of-the-mill hygiene is so much better in circumcised males. This is something that washing with soap just can't fix, because the bacteria return quite quickly in uncircumcised males," he says.

And female genitals? Other parts?

... Morris claims that the medical benefits of circumcisions are such that the procedure should always be considered a direct medical need.

Morris needs a dictionary that will properly define need, preferably in a medical context.

Morris says one in three uncircumcised males will suffer an illness that will require medical assistance for a disease directly related to not getting circumcised. From this perspective, Morris argues, it is unethical not to routinely circumcise given the relatively simple and painless nature of the process and the harm that can be avoided.

Do women who get breast cancer suffer a disease directly related to not getting a mastectomy before cancer strikes? Morris is playing very loose with logic, yet he gets featured as if he's the reasonable voice. The best¹ the reporter can apparently do to counter Morris is this:

That both pre-pubescent boys and adults can undergo circumcisions might support Mason's contention that the matter should be left until the child can decide for themselves.

It's not "now or never" for circumcision and all its allegedly wonderful benefits. That's a large caveat in favor of considering ethics and human rights, no? And maybe it suggests a more vigorous examination of the bit where Morris equates potential benefits to direct medical need than the reporter attempted?

Finally, via Religion Clause, an article from World Net Daily about a lawsuit in Italy over infant baptism. This particular aspect stood out.

[Alliance Defense Fund senior counsel Joseph] Infranco said, "All parents have the right to raise their children in their religious tradition, which obviously includes participation in the historic rituals associated with that religion."

We could discuss baptism, and I'd probably agree with this statement. But it's far too broad. If we can judge psychological harm, then no, I won't concede the point without a debate. If we can judge physical harm, then I will never concede the point. Historic or not, ritual or not, there is no defense for permitting parents to impose physical harm. Children have individual rights - particularly to their bodily integrity - that can't be ignored in favor of imagined, non-existent rights to treat individuals as collective property.

I didn't really stick with the quick hits, did I?

¹ For those who wish to mix issues and push for nationalized healthcare as a strategy to reduce infant circumcision, the reporter dropped this into its own paragraph as a defense for the clear intention of the article. I think America would see this emphasis on long-term costs more than an emphasis on short-term costs. Or rights.

Reducing the burden of diseases later in life would also save money in the already over-stretched health budget.

When the choice is between hubris and rights, central planners will always choose hubris.

August 07, 2008

Monkey Smile Jamboree

In three minutes, this video neatly summarizes much that is wrong with the American mindset surrounding infant male circumcision.

After a bit about "what is circumcision", we have this exchange:

Teen: "Does it hurt the baby?"
Adult: "It doesn't feel good, but they don't remember it."
Teen: "Yeah, but it doesn't matter the memory of pain, it matters the pain or not."

The teen has a natural, reflexive push for simple logic. She gets it entirely correct. As I've argued before, following the "he won't remember it" angle could justify anything short of murder. Something else (ethics, medical need) must get in the way, rendering "he won't remember it" irrelevant. He will experience it. That matters.

Continuing on through the video, the adult pushes to replace logic with emotional conditioning. One of the teen girls asks why all (circumcised) men have "an awkward scar around their penis". After laughter and a bit of disbelief, the adult responds:

"He's talking about probably the separation from the shaft and the head, okay?"

This is ignorant. A scar results from every circumcision. It may be at the separation of the shaft and the glans, although it's usually further down the shaft than that. (Not much, unfortunately, since there are nerve endings in the now-excised foreskin.) But there is a scar. No circumcised male is unique in being free of this inevitability. Any person who's seen a circumcised penis, or even the result of another surgery, knows this if he or she is willing to acknowledge reality despite its interference with preferred fantasy.

Next comes the low point of the discussion from the adult:

"You want your husband or boyfriend or whoever... your husband, yeah, there we go, to be circumcised."

If I told my (fictional) son that he wants his wife or girlfriend or whoever to be large-breasted, implying that he shouldn't be with a smaller-breasted woman because their natural bodies are defective, you would consider me a piggish ass. Rightly so. Forcing one person to conform to the opinion of another is wrong. Including when it involves surgery. Especially when it involves children.

We all remember our economics, right? All tastes and preferences are subjective. Even if I ignore the preferences of the male subjected to circumcision so that he will presumably please his future partner's aesthetic preference, as this woman does, what about the subjective tastes and preferences of these females? They're entitled to their own opinion, as long as it's the adult's opinion that foreskins are gross? Conformity for all? That is wrong.

Apart from witnessing how the development of a young mind is perverted by an adult's careless lack of curiosity, this video is instructive of how males are not the only people injured via circumcision. We expect conformity among females. They just get less unlucky in this debate. We achieve their conformity through manipulation rather than mutilation.

July 10, 2008

There is no free in prevention.

This article about serious side effects possibly related to Gardasil is mostly speculation. Point conceded, so I won't use it as fact. Instead, it's worth considering the ethical questions. The (doctor) father of one teen believes Gardasil caused the medical problems his daughter now faces. (Correlation is not causation, of course.) He said:

One thing that's different about Amanda's case than some of the others is that both of her parents medical doctors who didn't think twice about having their daughter get the shot – but are now second-guessing themselves. They call their daughter's illness after Gardasil "a very sobering experience." Amanda's dad says, "as the father of three girls, I've had to ask myself why I let my eldest one get an unproven vaccine against a few strains of a nonlethal virus that can be dealt with in many more effective ways. It's not like they are at high risk. It was the regrettable acceptance of the vaccine party line that [mis]led me."

Don't get distracted by "unproven vaccine" or "nonlethal virus". They're important in both the medical and ethical evaluation, but "can be dealt with in many more effective ways" should be the focus.

Merck, which makes the vaccine, the CDC and the FDA all say it is safe, effective, and important. Speaking of more than 8,000 adverse event reports and more than a dozen deaths, the CDC told CBS News, "we have found no connection between these deaths" and Gardasil. "We still recommend the vaccine and feel it is an important vaccine for the health of women. There are about 20 million people currently infected with HPV. Women have an 80 percent chance of developing HPV by the time they are 50. HPV is most common in people in their late teens and early 20s. Because the vaccine is a preventative and not a cure, it is important that the vaccine be given prior to beginning sexual activity. About 11,000 women will be diagnosed with cervical cancer and 3,600 will die. This vaccine prevents four viruses that account for about 70 percent of cervical cancers." [emphasis added]

The CDC ignores the necessary caveats. It is important to give the vaccine prior to beginning sexual activity if the female will engage in risky sexual behavior and/or weighs the risk of infection greater than the risk of possible adverse reactions to Gardasil, among many factors in the decision. Parents can't know the answers. They can assume, but assuming involves risk greater than they should impose. The threat of HPV is serious but infection is neither automatic nor inevitably deadly. Waiting involves additional risk. But risk involves rights. That can't be forgotten.

July 07, 2008

If there is a better private system, this is not it.

I'm a libertarian because maximizing individual liberty is the primary goal of collective human action. Whatever the means, achieving maximal individual liberty is the end.

The question is, of course, by what means? I've toyed with the idea - to be honest, not seriously - of no government. I understand and accept the idea that private processes would develop in the absence of a formalized government. The protection of rights present¹ in our current system of government would largely remain. However, given human nature, there is too great a threat to individual liberty inherent in no formal government. A monopoly on force is dangerous, but no such monopoly is not automatically better for the individual. A government with limited, stated powers designed to protect the rights and liberty of all its citizens is, I believe, the ideal.

That is the ideal. We don't live in libertopia, though. Such a government must exist with its limited powers explicit and limited only to protecting rights. I use the term collective human action above to express this narrow, rigid concept of legitimate government. We act together specifically so that we may be free from each other generally.

Since a government's objective is to maximize liberty, I'm interested in minimal restrictions on individuals. The valid test for restricting an individual's free action is objective, unrequested harm. Where an action causes such harm, a government's power to restrict the action is legitimate. Beyond that boundary, any government action is a violation of the powers granted to it by its organizers.

(There is a large, important gray area concerning subjective harm. Although it must be explored to develop a complete political philosophy, I leave that discussion alone for my purposes here. It's pointless to consider the subjective before settling the objective. It is also unnecessary because I wish to consider only objective harm here.)

So, circumcision.

A recent string of Free Talk Live episodes discussed circumcision in the context of how far states should go in preventing child abuse. The show's hosts generally take an anti-state position, relying instead on the expectation that private systems will fill the void if we dismantle the state. In many cases I'm sympathetic to this view. Particularly with economics and all the ways in which our government seeks to improve our world, the state makes obvious, large mistakes because it must plan rather than rely on ever-changing needs to direct the market. But in matters of protecting rights, I am not sympathetic to this view. The state is a means to protecting rights and achieving individual liberty. This function is necessary in any society, and the properly-constrained state is the least bad option. "Properly constrained" is the key, of course. I do not foresee a private market in force being any more properly constrained than the state yet still undertaking the necessary task of protecting citizens.

From the June 11, 2008 episode (approximately 1:26:45 in):

Mike (Caller): So I think we've all agreed that at three or four years old, a child cannot make a rational decision.
Ian: I would certainly agree with you. No doubt about it. And here's what I would suggest. You should go and live on a piece of property that has deed restrictions or private law, whatever you'd like to call it. You can call it deed restrictions, you can call it private law. Then, you know, in that world of private law, you can construct and create whatever sort of rules you want to as far as the behavior of your neighbors is concerned. And if you want to ban things like mutilation, or hitting children, or whatever it is that you consider anathema to your belief system, it would not be allowed by punishment of whatever it is that you determine the punishment should be.
Mark (Host): And before one moves to that community, they have to agree upon those rules.
Ian: Right. Then you wouldn't have anyone around you that was doing those awful things and you wouldn't have to be concerned with it. And then those who wanted to mutilate their children, or whatever, could go and live together in their own little, you know, their own little society.

Being anti-state is the wrong way to approach this issue as a libertarian. Certain rights are inherent and universal to all humans. Do the children in the latter community not have the same rights they'd possess if born in the former community? Children would not choose these community rules as adults would, so the protection of rights become merely the will (or whim) of the strong. Suggesting this as a viable option towards maximizing individual liberty treats children as property. What is it worth to be free of force from the state if you are not free of force from your parents?

Maximizing individual liberty requires limiting an individual's liberty to the extent that his unfettered actions would infringe on another individual's liberty. Doing so in that limited manner protects individual rights. We can argue whether the state or some other method is the best way to maximize individual liberty by protecting the rights of all individuals, but there is no valid argument that this should not be the primary goal of any society.

On June 16, 2008, a caller continued the discussion on circumcision (approximately 17:40 in):

Dan (Caller): Hi, Ian. Umm, a couple weeks ago, or maybe it was last week, I'm a podcast listener, so I get times mixed up.
Ian (Host): Okay.
Dan: There was a gentleman who called in, actually, a couple Christians who called in talking about how they don't want to force their morality on people but, you know, if people are, you know, abusing their kids and you've got to do something, you've got to have the government around to do something. And I just wanted to submit that in a totally free society where you have, you know, where people have the liberty to basically do what they want as long as they're not hurting anyone else, you're still going to have people hurting each other, but it's no different than today. My point was going to be that, uh, why can't the kids, if they have a case that they've been abused, uh, why can't they just sue in retrospect?
Ian: They should be able to.

That continued after a commercial with a restatement (approximately 20:04 in):

Dan: Ok, um, I was talking about how there have been some Christian libertarians who have been calling in talking about how, you know, they they just can't accept the idea that we have to allow everyone full liberty to raise their children how they want to, you know, because, you know, what if, well what if they're, you know, doing something like, you know, they brought up female circumcision or something like that.
Ian: Yeah.
Dan: And what I was saying is why, you know, the burden of proof should be on the accuser. So why don't we allow people to do, to, you know, to raise their kids as long as there's no clear signs of abuse, and if the children are damaged by it, sue in retrospect. That rather than having the burden of proof constantly on the parents so they have to prove to this government that we have constantly that they're not abusing their children.

Proposing a post facto process for recourse in the event of harm is a no-brainer. (What system of mediation, if not the state's legal system?) We have a system for this today that covers all sorts of offenses that are also a crime. Obviously harmed individuals have a claim to compensation against those who harmed them. Offering that as a substitute for prohibition avoids the real issue of rights violations. We prohibit certain assaults despite having options for restitution after the assault because protecting the right of every individual to be free from harm is at the core of liberty.

Unfortunately the typical libertarian approach to hypothetical questions seems to revolve around the assaulted being able to pull out his concealed weapon and stop the assault, hence no need for the state. I exaggerate wildly, even though my hyperbole is useful in hypotheticals because adults have some ability to defend themselves, whether through brains, muscles, or technology. There is merit to the argument of self-defense. But we're not discussing adults. Many, if not most, minors lack sufficient resources in these defense mechanisms. Infants lack all resources. Yet, as citizens with equal, natural rights, all minors must be treated as more than inconvenient obstacles to extending hypotheticals into real world rules. The notion that children complicate libertarian political philosophy - or worse, that libertarianism does not apply to children - is a failure of application, not the underlying principles of liberty and rights. The reasonable concept of proxy consent matters because parents are the proper decision-makers where necessity demands it, but proxy consent does not matter most. No adult has a legitimate claim to violate those rights merely because he or she is the child's parent.

Permitting parents to surgically alter the healthy genitals of their (male³) children grants them an illegitimate liberty interest in altering - and harming - the body of another at the expense of his legitimate liberty interest in self-ownership, a right that includes his foreskin. Endorsing that because it precludes state involvement, even with a post facto compensation system in place, turns antipathy for the state into a fetish, at the expense of individual liberty. Being oppressed in private is still oppression.

The debate continues (I've omitted an inconsequential bit):

Mark: Ok. Yeah, absolutely true. Umm, I think that, uh, people that have been, you know, harmed by their parents in some way should be able to sue and umm, I would think in the case of a female circumcision that likely they would, uh, you know, a jury would find for them. Umm, male circumcision, maybe not so much. You know, pervasive morality matters in a, in a society, and if you're going to get a jury of your peers, you know, they're probably not going to find that you were harmed significantly by a male circumcision. Maybe they will, I'm not sure.

It's a strange kind of libertarianism that places the "pervasive morality" of the majority before the protection of individual rights and objective standards of harm.

Continuing, with omissions for space:

Ian: You mean Dan's idea?
Mark: Yeah, Dan's idea would be, would take care of it relatively quickly because, well, people don't want to be sued.
Ian: Well, right, because, uh, if there was a judgment against the parents in that particular case then, uh, then the other parents that were considering doing that would have to think twice.
Mark: Absolutely. And of course social ostracization would, uh, keep these types of things from really cropping up within private, voluntary societies so you'd have private arbiters, you'd have parents who, and uh uh and new new parents who would already have signed on to the rules. And, uh, man, if they broke those rules, they would not be able to prosper, and they would be hit pretty hard financially.

There is some merit in this argument, but as it applies to doctors, not parents. That's already starting in the U.S. It will have more impact as the courts become more sympathetic to the proper inclusion of medical ethics into unnecessary genital cutting.

With parents, we're back to being stuck with the pervasive morality of the majority at the time of the circumcision, and parents already ignore what their son may or may not want in favor of what they think he wants, or worse, what they want. That misses the point. A male can later make the case that he was harmed, but this solution relies on two faulty assumptions. First, it assumes the male minor's (obvious) rights aren't worth protecting while he is a child, perhaps merely because his parents circumcised him rather than a stranger. Their liberty is more equal than his liberty. This can never be correct.

Second, it assumes that money will sufficiently compensate him for his lost foreskin. Not all men would accept that trade-off. Not all parents will be able to fund a judgment against them. And if they don't expect to have the resources in the future, would the parents be concerned enough about a possible future judgment to not circumcise? Nor will all parents with the financial means to fund a jury's punishment value the lost dollars more than whatever value they place on the act of circumcising their sons. Remember, all tastes and preferences are subjective. Just as the evaluation of the foreskin's worth will vary by individual, the evaluation of the worth of a dollar (or a million or a billion) relative to pleasing God/a perceived reduction in HIV risk/avoiding the "ick" factor/etc. will vary by parent(s). There simply is no reliable way to predict what individual's will do. Incentives matter, but not everyone responds the same way to the same incentives.

This hypothetical system also ignores the extreme cases where the harm to the boy is greater than the typical circumcision outcome. It seems reasonable to suggest that the rare boy who dies from circumcision will not be satisfied by the possibility of money he can't collect.

We're left with individual rights as the only defensible guide for what system should be in place. I can't make this point enough. Every individual, regardless of age, has the same natural rights. An age-based inability to defend one's own rights does not render those rights subject to the will of another, even a parent. What system will protect those inherent, equal rights? If you value liberty, that is the discussion. If you value only the dismantling of the state, understand what your position entails. Don't wrap it in talk of liberty and pretend you've found an intersection that bypasses the state. You haven't because compensating the violated after an identifiable, predictable violation rather than protecting before the violation has nothing to do with liberty.

I'll end with a concise statement of the philosophical consideration at hand, from D.A. Ridgely at Positive Liberty (from a different context):

The quintessentially libertarian position, in any case, is that the burden must fall on the state not before it permits some exercise of individual freedom but before it prohibits it. It is, by contrast, the quintessentially conservative position (of the Burkean variety) that tampering with long established traditions and institutions is so inherently risky that we must apply the social equivalent of the precautionary principle before proceeding.

I'm arguing the quintessential libertarian position. I'm not willing to concede that parents have an absolute right to make medical decisions for their children. Such a right assumes the option to make objectively stupid medical decisions for another. I'm thinking of parents who let their children die while waiting for prayer to save them. Still, parents deserve at least first - and great - deference to their judgment. The burden falls on the state to prove that it may prohibit the circumcision of minors. Where direct medical need is absent, as it is absent in ritual/social circumcision, the objective infliction of harm on the child to achieve subjective benefits valued by the parents, however well-intentioned, is sufficient proof that state prohibition is not only legitimate, but a requirement to protect rights and maximize individual liberty for everyone. Imposing routine/ritual circumcision is not a medical decision, so the decision deserves no deference. Whatever system is in place must recognize that and protect the child. The private system proposed by Free Talk Live is unacceptable because it fails to embrace liberty for all.

¹ Admittedly, our representatives disregard this duty. This is a flaw in execution, not design. But it's presence in our government is a significant, complicating issue.

² By force, I mean objective harm. The state does not have the constitutional power to cut your genitals at the discretion of its representatives, at least not without due process. (Also, see footnote ¹.)

³ The distinction permitting only the circumcision of male children demonstrates our unprincipled, unequal understanding of the rights of children.

July 06, 2008

Is this an M.D. from a correspondence school?

When public health officials say voluntary, adult, ...

The soldiers in the Rwanda Defence Force (RDF) will be the first men to benefit from a government policy to use male circumcision as a tool in the fight against HIV/AIDS, according to senior health officials.

... The voluntary circumcision programme is expected to start in August.

"We will use the military as role models for the rest of the population – they are adult enough to give consent, and if young men see that soldiers are willing to suffer the pain of circumcision, they will also get the courage to do it," said Dr Agnes Binagwaho, executive secretary of Rwanda's national AIDS commission (CNLS).

... they never mean voluntary, adult. Never.

"After the military we will concentrate on students and, finally, on the general population; eventually we hope to move on to circumcising new-born babies, as long as research proves that it is advantageous and cost-effective to do so."

Want to bet research will prove that infant circumcision will be advantageous and cost-effective, in spite of reality that Rwanda has "only one doctor for every 50,000 people"? Should it skew the analysis against infant circumcision that the rate of HIV infection in Rwanda is higher in circumcised men than in intact men? Of course, but it won't. It's so much easier to blame the foreskin than the male attached to the foreskin.

----------

Also, should we put trust in Dr. Binagwaho when she couldn't pass a basic statistics class?

"People must be made aware that although circumcision is beneficial, there is still a 40 percent risk of HIV transmission, so they must know that it must be used in conjunction with another HIV prevention method, such as condom use," she said.

I expect those unfamiliar with statistics to make such a mistake. Is it too much to expect a doctor to be familiar with statistics?

----------

Post Script: Based on the article's closing paragraph about funding for Rwanda's circumcision plan, I feel confident that I will eventually be able to remove my updated qualification from this entry. The plan outlined in the article is stated in Rwanda Fiscal Year 2008 Country PEPFAR Operational Plan (COP). We will continue throwing money at this ignorance.

Pitting anecdote against anecdote ignores reason and logic.

There is much to commend in this article, but like all attempts to be unbiased on a topic where introducing subjectivity is the only method for achieving balance, the conclusion veers into scare tactics.

[Opponents] declare [circumcision] mutilation.

But there is another side to the story.

Dave, who didn't want his full name used to protect the privacy of his circumcised 19-year-old son, objected to the practice after his son's birth.

"I went through it, and I didn't want him to go through it," said the 48-year-old electrical engineer from Chantilly in Northern Virginia. "They cut millions of nerve endings that would be nice to have." [ed. note: thousands of nerve endings]

But, as his son grew, he couldn't pull the foreskin back far enough to clean it without significant pain. He stopped cleaning, and infection after infection of the penile head and foreskin ensued, turning his penis beet red.

"We ended up doing the circumcision when he was 5," Dave said. "It was awful. For years after, he got into the bathtub only gingerly, putting his hand over those parts the whole time."

Now, Dave advocates having the procedure done as soon as possible after birth.

"My son suffered by not being circumcised early," he said. "And I wonder what long-term impact that has had on him."

This is not another side to whether or not it's appropriate to circumcise healthy male infants/children. This is an emotional appeal to a child's ability to remember surgery and the unlikely-but-possible risks of life. Even a cursory look at circumcision statistics in other Western countries will confirm this article's anecdote to be devoid of any merit as a defense in favor of imposing surgery on healthy children to avoid risks later.

It should be clear that I understand some males will need medical intervention on their genitals if left intact. (And if circumcised.) That is not then justification to circumcise children. Many females (and some males) will eventually need some kind of medical intervention for breast cancer. We do not see that as a defense for removing the breast tissue from infants because we are not irrational on that front. Apply a speck of reason and the similar excuse for male child circumcision fails.

To the anecdote directly, I can only speculate. It is not unusual for the foreskin of a five-year-old boy to at least partially adhere to his glans and inner foreskin. Pulling the foreskin back further than it can easily retract is bad and can cause pain. (Almost as bad as forcibly separating the foreskin from the penis prior to circumcision.) Perhaps that occurred here. I've certainly heard of parents being aggressively determined that the foreskin should retract fully before it naturally separates. This can lead to problems.

But, again, I'm only speculating. Speculating is pushing limited facts into a preferred narrative. Dave speculates to the reporter. (Circumcised males get infections.) I'm speculating here to illustrate the process. I don't need speculation to defend my position. I'm willing to concede that Dave's anecdote is exclusively an example of the risk of being intact. It happens, unfortunately. But where his stance needs speculation and anecdote, I have reason and evidence:

"... And, urinary tract infections are so rare in baby boys that the increased risk of it isn't significant," [pediatrician Roxanne Allegretti] said.

Anecdote of the "my best friend's cousin's first-grade teacher's next-door-neighbor's driving instructor once had <insert problem here> with his foreskin, leading him to get circumcised at <insert age here>, and he definitely remembers the horrible pain" is not a compelling reason to perform surgery on healthy children. Healthy and surgery are mutually exclusive for those who can't consent.

July 05, 2008

The ability to reason includes recognition of gender-bias.

Ignorance can speak truth, even when ignorance doesn't intend something so broad (emphasis added):

... I feel that "female circumcision" gives this practice a veneer of respectability to hide behind. Uninformed people likely know that male circumcision is done mainly for hygienic or religious reasons and has nothing to do with sexual pleasure or causing other problems down the road, as mutilation may cause with menstruation and childbirth. Circumcision is pretty much the opposite of mutilation as far as having an effect on a person.

So "female circumcision" sounds kind of like a benign minor medical procedure, while "female genital mutilation" tells it like it is. I don't think calling the practice circumcision will fire many people up against it - it almost sounds like a P.R. phrase for genital mutilation, designed to mask what really happens.
This practice has also made its way to the United States, through immigration.

I don't think calling the practice circumcision will fire many people up against it - it almost sounds like a P.R. phrase for genital mutilation, designed to mask what really happens. Indeed. It's almost as if Americans embrace that mentality with our treatment of male children. Almost, of course, because only They™ engage in immoral actions. We™ are always correct, never to be questioned again.

I will be using that quote frequently in the future.

July 01, 2008

Central planning isn't just for economics.

I wonder if these two Ugandan MPs have ever spoken to each other. First:

THE parliamentary food forum has asked the Government to provide funds for the a campaign against female circumcision. Addressing journalists at Parliament on Friday, Bukwo Woman MP Everline Chelangat urged the Government to establish vocational institutions for girls to fight the custom.

Second:

THE chairman of the parliamentary HIV/AIDS committee has appealed to men to embrace circumcision to reduce the risk of contracting the virus.

“There is nothing to lose when you remove the fore skin of the penis. Men who are not circumcised are more prone to HIV/AIDS,” Dr. Elioda Tumwesigye said on Saturday.

Dr. Tumwesigye is wrong about what a man loses from circumcision, and he is too broad in his declaration of the benefit against HIV because he ignores the necessary contributing factor, an HIV-infected female partner and condom-less sex. But where he accepts the distinction of choice in losing his perceived nothingness, these statements on male and female genital cutting are reasonably congruent, if slightly tone-deaf. As I've always advocated, I do not care what an adult - male or female - chooses to do to his/her genitals. Leave it alone or hack away. MP Chelangat is clearly arguing against forced cutting. I just wonder whether or not that distinction of choice exists in Tumwesigye's intent:

Tumwesigye noted that attempts to make circumcision compulsory for men had failed because of the misconception that it was a practice only for Muslims.

I won't read that as a statement that Tumwesigye isn't interested in choice, although I think such an inference makes sense. Where are those attempts originating? If that's what he's saying, I'm not surprised. Respecting the science makes many doctors forget the ethics. I don't know why, but it does. I think I'll have more on that idea in the near future.

There isn't much more to say than, from a marketing perspective, it's fascinating that these two articles appeared on the same day in the same news outlet.

June 26, 2008

The facts are, in fact, relevant.

In response to the Jeremy Kuper essay I criticized yesterday, Laura MacDonald writes an excellent rebuttal demonstrating how little attention Kuper gave the topic beyond the superficial evidence that he believes supports his decision to circumcise his son. This is excellent:

Specifically, let's talk about the foreskin itself. Its function is – bizarrely – one thing you'll find absent in most of the discussion articles written about circumcision.

... Often presented as a "tiny" vestigial flap of skin, most particularly by women and by men who haven't got one, a male foreskin measures around 10-15 square inches when unfolded, some 50% of his overall penile skin system. ...

Right, then. Next time they'll try harder, I'm sure.

For the sheer giggle factor of proving how extreme and indefensible circumcision is when compared to other interventions (i.e. condoms), this:

There is no convincing proof that circumcision reduces sexually transmitted infections in developed nations, and its effect on penile cancer rates is similar to that of soap.

I know. Soap, the preposterous suggestion we needn't bother offering to men. Especially since they won't need soap after circumcision. Or does that not make any sense? Whatever. As long as parents get to cut their children in the end, every absurd justification is logical.

June 25, 2008

"Research" is easy when you seek only approval.

In an attempt to defend the indefensible (i.e. circumcising his healthy son), Jeremy Kuper writes a rambling, disorganized essay at Comment is Free that skims only the surface on each aspect of the debate. Moreover, he includes the euphemism "member", so the weight of his position automatically suffers according to my rule on penis euphemisms. You can read the essay, if you're interested, but I already wasted enough time for all of mankind. Consider it not worth your time. And as proof, Kuper writes this near his conclusion:

Possibly the worst effect of circumcision for Jewish people, is the accusation that it is a form of mutilation, and cruelty to a small baby who is unable to give his consent.

Merriam-Webster defines mutilation as "to cut up or alter radically so as to make imperfect" or "to cut off or permanently destroy a limb or essential part of". Someone takes a blade to a child's healthy genitals and removes a functioning part of the body. Are we going to quibble over "essential", because in the context of the foreskin, the clitoris holds no greater objective essentiality. I am not making an accusation that circumcision is a form of mutilation. I am stating the obvious truth that all forms of genital cutting on healthy, non-consenting individuals is mutilation.

Some uninformed critics even appear to confuse it with the horrendous practice of female circumcision, and the removal of the clitoris in some cultures, which is now largely banned. Dr Nahid Toubia argues that the term female circumcision "implies a fallacious analogy to non-mutilating male circumcision".

Kuper is the uninformed individual in this debate. I "confuse" male and female genital cutting because they are the same act: medically unnecessary genital cutting on a non-consenting individual. That's not a complicated analysis to arrive at. A few minutes spent objectively considering the act of circumcision could get to that understanding, even if he was unwilling to accept the comparison.

A few more minutes spent researching female genital cutting would demonstrate that removing the clitoris is FGM, but FGM is actually a spectrum of offenses that involve surgical alteration of the female genitals. A quick trip to Google reveals the four recognized types. At least one type is no more damaging than male genital cutting, yet all non-medically-indicated female genital cutting is illegal in Western societies. If I am to be the person who is wrong in this debate, then Kuper must defend the position that legislative bans on all female genital cutting are too broadly defined.

He must also reject the Western liberal tradition of gender-neutral equality under the law, but I'll accept one concession to facts and modernity if his ego can't handle an honest, complete exploration of the topic.

There is no do-over in surgery.

I'm still catching up on some of the circumcision-related news items form the last few weeks. Sometimes, I step away from the topic for short periods to recharge my tolerance for the inevitable frustration that arises when considering the various ways the rights of the circumcised are ignored, and the manner in which every breathless proclamation seems to instill even more determination that every male will just love being surgically altered shortly after birth. Stepping away eliminates reduces the number of verbal tirades I feel compelled to unleash. I always come back, though.

This story, forwarded to me by a loyal reader who forwards me useful material that I too often fail to translate into entries, is worth mentioning. Now that I'm looking, I can find a few references to it, but most media seems to have ignored it. Probably because it directly challenges the cheerleading for infant circumcision in the recent past. Anyway, the gist:

A quarter of a century after the outbreak of Aids, the World Health Organisation (WHO) has accepted that the threat of a global heterosexual pandemic has disappeared.

In the first official admission that the universal prevention strategy promoted by the major Aids organisations may have been misdirected, Kevin de Cock, the head of the WHO's department of HIV/Aids said there will be no generalised epidemic of Aids in the heterosexual population outside Africa.

This is the appropriate point to remind everyone - the unethical scientists at WHO specifically - that the recent research we've been bombarded with repeatedly for the last two years suggests that voluntary, adult male circumcision reduces the risk of HIV transmission from female-to-male through heterosexual intercourse. Those infants who've been circumcised in the mad rush to embrace fear unsupported by at least the anecdotal evidence any mildly observant individual in a Western society could pick up? Ooops. But, hey, women will dig it, so there's that.

In case you think this might cause the media to apply any critical thinking to the way they've reported on circumcision, fret not, they're fully prepared to let you down if you get optimistic. In the same article, this:

Critics of the global Aids strategy complain that vast sums are being spent educating people about the disease who are not at risk, when a far bigger impact could be achieved by targeting high-risk groups and focusing on interventions known to work, such as circumcision, which cuts the risk of infection by 60 per cent, and reducing the number of sexual partners.

Interventions known to work. Process that for a moment. It's known to work¹ at reducing the risk of HIV transmission from female-to-male through heterosexual intercourse! Isn't the point of this story to report on the possible exaggeration of an epidemic among heterosexuals? I can imagine the editorial review of this article. "Everyone, shake your pom poms with me. Give me a "C"! Give me an "I"! Give me an "R"! Give me a "C"!

I won't put it in print, but I'm swearing right now.

¹ There is room to debate this, primarily on methodology. Another time, perhaps.

June 23, 2008

Your honor: peas or carrots tonight?

Via Amy Alkon, a story with some relevance to my stance that medically unnecessary male circumcision of all minors should be prohibited (and enforced, where necessary) by the state. From Canada:

A Canadian court has lifted a 12-year-old girl's grounding, overturning her father's punishment for disobeying his orders to stay off the Internet, his lawyer said Wednesday.

The girl had taken her father to Quebec Superior Court after he refused to allow her to go on a school trip for chatting on websites he tried to block, and then posting "inappropriate" pictures of herself online using a friend's computer.

In the case of cultural circumcision, which includes medicalized circumcision that seeks potential health benefits, the obvious first standard for what to prohibit is objective harm. Circumcision is surgery, so it always involves objective harm to the body. When there is no medical need for the surgery, forcing it on another person is an assault, regardless of the intent. Preventing this type of harm to one by another is a legitimate function of any state. Prohibition of medically unnecessary circumcision forced on minors is valid. QED.

Discussing the male circumcision issue within the libertarian community is an interesting process. Strangely, many libertarian males seem displeased, however mildly, about their parents circumcising them. Yet, in an odd consideration of limited government and individual liberty, they also seem reluctant, often vehemently, to consider state involvement. This is more a misdirected focus on minimizing the state as the ends than on maximizing liberty with the best, possibly necessary means. (More on this to come in a detailed post I'm working on.)

But there is a limit to legitimate state intervention. Always, the first response I get in the libertarian discussion is that parents make all kinds of decisions for their children that the child may not like, should we legislate those? I think that logical leap is lacking in logic, but it's not (generally) offered with malice, so it's worth considering. I usually discuss some combination of objective harm and the permanence of choices. Unless one is being intentionally ridiculous, it's worthless to advocate an exact comparison between requiring your child to take piano lessons and requiring him to undergo unnecessary surgery that removes portions of his healthy, functioning anatomy. "Requiring" is a key word in considering intervention, but "unnecessary" is the much more important word as it ties directly to objective harm. Surgery causes objective harm in a manner that piano lessons do not. The difference, to some degree, is parenting. I do not favor state intervention in normal parenting, nor have I written anything that could be construed as favoring limitless intervention. I offer specific guidelines for legitimate state intervention.

Which brings us to this case from Canada. I guess it's possible that there's more to the case than the reports I've read. It seems hard to believe that, so I will assume there is nothing more. So, this judge made an egregious error. The state's intervention is illegitimate.

It's not controversial to accept that, which gets us back to the more fundamental issue. What is the legitimate boundary for state intervention? It's somewhere short of this case, we all probably agree. It's at least as far as prohibiting the assault of children, however well-intentioned. We don't all agree, or I wouldn't be writing this. But I've made an argument in favor of my stance that outlines criteria for deciding how to limit or condone state involvement in parenting decisions. This case shows that my effort is an attempt at an objective standard that aims to protect the rights of all individuals, regardless of their power within society based upon having not reached the objectively arbitrary age of majority.

Are we angry about the assaulter or the assault?

I only know the facts to the extent that the article states:

School board members voted 5-0 to fire Mount Vernon Middle School science teacher John Freshwater. Board attorney David Millstone said Freshwater is entitled to a hearing to challenge the dismissal.

Freshwater denies wrongdoing and will request such a hearing, the teacher's attorney, Kelly Hamilton, told the Mount Vernon News.
...

Freshwater used a science tool known as a high-frequency generator to burn images of a cross on students' arms in December, the report said. Freshwater told investigators he simply was trying to demonstrate the device on several students and described the images as an "X," not a cross. But pictures show a cross, the report said.

I stand firm on innocent until proven guilty. Until he has a hearing, I'm not interested in saying much more than anyone who would teach religion in a science classroom is not qualified to teach science. I hope it's obvious that anyone who would burn an image on a child's arm, be it an "X" or a cross, is fit only to wear a prison jump suit.

That said, is this about violating the First Amendment rights of the children or violating their human rights? Change the scenario: would we allow parents to burn an image of a cross on their child's body? Many will reflexively offer some variation of "of course not". But that's not accurate. We already allow parents to "burn" a (permanent) religious mark on their (male) child's body through genital mutilation. And that doesn't disappear in three or four weeks, as the burned image of the cross/"X" disappeared. Why is the less damaging, less permanent assault reprehensible and the more damaging, more permanent assault considered a reasonable parental choice?

June 03, 2008

Advocating logic is undesirable, like practicing unsafe sex and sexually assaulting women.

Still catching up from the last two weeks, this was in the first draft of my last entry. It got a bit too long, so it became a stand-alone entry.

Via Andrew Sullivan, this quote from UNAIDS on travel restrictions placed on HIV-positive individuals by the United States (pdf):

UNAIDS recognizes that States impose immigration and visa restrictions as a valid exercise of their national sovereignty. However, in imposing any restrictions on entry and stay relating to HIV or health, UNAIDS calls upon States to adopt non-discriminatory laws and regulations which rationally achieve valid objectives through the least restrictive means possible.

UNAIDS would like to take this opportunity to reiterate that HIV-related travel restrictions have no public health justification. It is also our view that, where such restrictions are based on HIV status alone, they are discriminatory. There is no need to single out HIV for specific consideration as an exclusion criterion. ...

Etc, etc. Exactly how much hypocrisy is allowed before principled becomes merely a mish-mash of preferred outcomes? How long ago did UNAIDS pass that point? A non-discriminatory recognition of human rights would be an excellent start, as opposed to something like this (pdf):

7.3 Since neonatal circumcision is a less complicated and risky procedure than circumcision performed in young boys, adolescents or adults, such countries should consider how to promote neonatal circumcision in a safe, culturally acceptable and sustainable manner.

Now compare with this, from the same link:

The message that male circumcision is very different from female genital mutilation also needs to be emphasized.

Or this:

Female genital mutilation, also called female genital cutting and female genital mutilation/cutting, violates the rights of women and girls to health, protection and even life as the procedure sometimes results in death.

Which can be said about male genital cutting. Still, UNAIDS doesn't discriminate because it puts this in its report on "Safe, Voluntary, Informed Male Circumcision and Comprehensive HIV Prevention Programming" pdf:

Governments that introduce or expand services for male circumcision will have a responsibility to
launch public health campaigns that:
...

(iii) emphasize the voluntariness of male circumcision;

(iv) clearly distinguish male circumcision from female genital mutilation, which is a violation of the human rights of women and girls, is illegal in most countries where it still takes place, has no health benefits and carries considerable physical and psychosocial risks for girls and women;
...

The male genital cutting UNAIDS pushes is hardly voluntary, which makes it a violation of the human rights of men and boys. But we can't say that because then we'd have to question what's been done to so many. Instead, UNAIDS needs to silence criticism by drawing odd, strained attention to only the outcomes that fit its narrative. (It is hardly alone in this, of course.) For example:

How is male circumcision different from female genital mutilation?

While both male circumcision and female genital mutilation are steeped in culture and tradition, the health consequences of each are drastically different. Female genital cutting or mutilation comprises all surgical procedures involving partial or total removal of the external genitalia (type I) or other injuries to the female genital organs. ...

And on it goes, willfully missing the obvious truth that the more than one million cases of "voluntary" male genital cutting or mutilation performed each year on infant males in the United States comprise surgical procedures involving partial or total removal of the external genitalia or other injuries to the male genital organs. The inherent human right to be free from that without consent does not disappear simply because cutting a boy's genitals might reduce his risk of HIV in the future if he has unprotected sex with an HIV-positive female.

Infant male circumcision: ethical, legal and human rights considerations

Studies have shown that the circumcision of infants is simpler and carries fewer medical risks than circumcision of older people. Parents considering circumcision of an infant boy should be provided with all the facts so they can determine the best interest of the child. In these cases, determining the best interests of the child should include diverse factors—the positive and negative health, religious, cultural and social benefits. Because the HIV-related benefits of circumcision only arise in the context of sexual activity, and because male circumcision is an irreversible procedure, parents may consider that the child should be given the option to decide for himself when he has the capacity to do so.

And given the irreversible nature of circumcision, what happens when a male decides that having his normal, healthy foreskin would be in his best interests? Setting aside the topic of (potential) health benefits for the moment, parents may argue for positive religious, cultural, and social benefits for female genital cutting. UNAIDS recognizes that none of those are legitimate, so it rightly dismisses them. Yet, because it's a penis, those same religious, cultural, and social benefits, as determined dictated by the parents suddenly matter? No.

So, yeah, UNAIDS is right on the U.S. denial of entry to HIV-positive individuals. But UNAIDS does not practice what it preaches.

Post Script: See the section of the report titled "Protecting Women in the Context of Male Circumcision" for an understanding of this entry's title.

May 17, 2008

The First Amendment does not grant the right to violate the rights of a child.

I've known about this for a little bit, but I hadn't planned to blog it because I don't think it will initially amount to much. But it's in the press now, so here's an update on the Oregon circumcision case:

A divorced father who wants to circumcise his 13-year-old son against the wishes of the boy's mother is trying to take his case to the U.S. Supreme Court.

James Boldt, who converted to Judaism, argues that preventing him from circumcising his son violates his constitutional right to practice his religion.

The U.S. Supreme Court accepts a small fraction of the appeals it receives. A decision on whether it will take the case is not expected until the fall [sic]

Earlier this year, the Oregon Supreme Court ruled that the trial judge should determine what the boy wants.

Obviously the mother, who is trying to prevent the circumcision, must approach this as if the Supreme Court will consider the father's request. I think she'd achieve the same short-term outcome if she ignored it because, until the trial judge determines what the boy wants, there is no reason for the U.S. Supreme Court to consider intervening.

That said, it might be interesting to speculate that the father is signaling something about the boy's wishes if he's wants to bypass his incomplete-but-favorable victory granted by the Oregon Supreme Court. But that would be speculation, so I will go no further until I know more.

To his claim that "preventing him from circumcising his son violates his constitutional right to practice his religion," every necessary piece of information you need is in that brief statement. His constitutional right, as an individual, can never legitimately include the option to surgically alter another person. That the other person is healthy is relevant but not necessary for consideration. That the other person is his child is irrelevant. "His child" is properly stressed as "his child". He is the child's guardian, not the child's owner. The child has his own individual rights that negate¹ his father's assertion that his religious requirement permits him to remove his son's foreskin.

Additionally, if the court is to recognize that a parent may circumcise a male child under the U.S. Constitution because a religious text tells them to circumcise, the court must also overturn the Female Genital Mutilation Act as an unconstitutional infringement upon this same alleged First Amendment right of parents to inflict genital surgery on their daughters because the law specifically excludes any parental claim to religion. If the parents have this right, it is plenary over all of their children, not just their children who were born with a penis.

Thankfully they do not have this right, so eventually this nonsense will lose its inexcusable credibility. Unfortunately, I expect the U.S. Supreme Court to botch this horribly on the barely non-zero chance that it takes the case. It will rule that the child has rights, but tradition makes this practice reasonable. (The Court will, of course, dismiss the truth that female genital mutilation is performed to adhere to tradition and social expectations.) The Court will also cite subjective benefits to male circumcision while ignoring the objective harm because the risks and inevitable outcome are "minor". Everyone but the boy's opinion matters. So, the most achievable path to Destination Sanity is clear, but arrival is probably not imminent.

¹ Much analysis in the news and blogosphere considers the importance of the child's age. At 13 he can make his wishes known. Yes, but the default presumption in our society - as shamefully demonstrated in the Oregon Supreme Court's ruling - is that we must decide whether the child's age overcomes the parent's wishes. That is incorrect. The default must be that the child would want his healthy foreskin because the alternative is permanent. Only medical need would allow the parents to make the child's decision until he can state that he wishes to be circumcised.

John McCain endorses majoritarianism over individual rights.

From John McCain's speech to the NRA:

Real activists seek to make their case democratically -- to win hearts, minds, and majorities to their cause. Such people throughout our history have often shown great idealism and done great good. By contrast, activist lawyers and activist judges follow a different method. They want to be spared the inconvenience of campaigns, elections, legislative votes, and all of that. Some federal judges operate by fiat, shrugging off generations of legal wisdom and precedent while expecting their own opinions to go unquestioned.

Is there an upper bound on how many individuals may have their rights violated before we conclude a constitutional solution is better than a democratic solution? If so, what's the number? Is there a distinction marking which rights are sacred and which may be violated at will by a majority? Is there any reservation worth considering to limit this complete trust in The People that might acknowledge those hearts and minds that are either incapable or unwilling of being won?

Like every politician, John McCain is a propagandist unworthy of being in a position of leadership. He will not behave as a leader.

May 16, 2008

Do a child's eyes belong to the child's parents?

As a thought experiment, consider:

LASIK surgery in children.

AIMS: To report success in the treatment of high myopia in children with LASIK. To report the visual results, complications and postoperative management of children with high myopia. METHODS: Six children (seven eyes) with high myopia were included in this series. Preoperative and postoperative refraction, visual acuity, and pachymetry were compared. RESULTS: Six children with high myopia ranging from -5.00DS to -16DS were treated. There were three males and three females. Five children had improved refraction and visual acuity post-LASIK. Age ranged from 2 to 12 years. Five of the children had unilateral amblyopia preoperatively. One had bilateral high myopia. CONCLUSION: High myopia in children may be treated safely and effectively with LASIK.

Now consider this story, via Amy Alkon:

Most Lasik recipients do walk away with crisper vision, and the American Society for Cataract and Refractive Surgery reviewed studies showing about 95 percent of patients say they're satisfied with their outcome.

But not everyone's a good candidate, and an unlucky fraction do suffer life-changing side effects: poor vision even with glasses, painful dry eyes, glare or inability to see or drive at night.

How big are the risks? The FDA agrees that about 5 percent of patients are dissatisfied with Lasik. How many struggle daily with side effects? How many are less harmed but unhappy that they couldn't completely ditch their glasses? The range of effects on patients' quality of life is a big unknown — and the reason the FDA help a public hearing Friday as part of its new move.

"Clearly there is a group who are not satisfied and do not get the kind of results they expect," said Dr. Daniel Schultz, the FDA medical device chief. The study should "help us predict who those patients might be before they have the procedure."
...

Doctors advise against Lasik for one in four people who seek the surgery, said Dr. Kerry Solomon of the Medical University of South Carolina, who led a review of Lasik's safety for the ASCRS. Their pupils may be too large or corneas too thin or they may have some other condition that can increase the risk of a poor outcome.

Solomon estimates that fewer than 1 percent of patients have severe complications that leave poor vision.

Should parents have an unchallenged option to choose Lasik surgery for their children for any reason?

Bonus question: Should they have that unchallenged option for only their children of one gender, with the exclusion based on a societal belief such as the (non-)desirability of glasses?

May 15, 2008

Judicial activism and Individual Rights

Obviously I think the California Supreme Court's ruling on same-sex marriage is the correct outcome. I'll leave the legal analysis of how the Court got there for others to judge. Still, this is an interesting, positive development.

I wish to comment on one factor that will appear in the coming weeks, and will probably quickly grow within the presidential election. Many will claim judicial activism, as if that's a valid claim. Our courts do not exist to rubber stamp any and every rule a legislature can dream up. Enforcement is the Executive's job. The Judiciary must interpret. Bowing to the mythical "will of the people" gets us no closer to the truth than waiting for a new constellation to appear in the sky with the correct outcome spelled in the stars.

An Andrew Sullivan reader wrote this to Mr. Sullivan:

...

The decision is an arrogant, impatient one. My gay friends are impatient, and I understand their impatience. But the Court should have trusted the people.
...

It was only a matter of time. A democratic consensus, based on reason and persuasion, is much better for everyone, in all the states, in the long run.

Mr. Sullivan responds with the perfect rebuttal:

Yes, and it has been building. But a republic is not just a democracy. It is a confluence of constitutions, laws, legislatures, executives and courts. In 1948, the California court ruled against miscegenation bans. It took three decades for that act of "judicial activism" to gain consensus nationally.

Exactly. And constitutions are first. Where the laws of the legislature violate that, the courts must reject the laws. Anything else is mob rule.

**********

This fits into the discussion on how civil law should treat medically unnecessary circumcision of male children in America. The procedure is ethically and scientifically flawed. It should not be permitted. Legislatures have already shown an willingness to exclude male children from this protection acknowledged for every other American. Democracy (i.e. mob rule), with a nod to social and religious justifications before individual rights protected by constitutions, should prevail, some say. What parents want is worth defending because altering the healthy genitals of their male children is their choice. It is a right that supersedes the rights of the child, both in individual religious freedom and bodily integrity/freedom from harm.

The political side of the issue is an unprincipled, anti-constitutional mess in America. The concept of individual liberty is lost. The court's role is to uphold constitutional protections for every individual. It is critical to defend the rights of the minority against the tyranny of the perceived majority. Where tradition and social expectations conflict with individual rights, tradition and social expectations have no merit. The role of the court is to set these legal excuses aside in favor of individual rights. This is not activism.

Courts are not infallible. Yet, as Mr. Sullivan's example shows, society has a way of catching up to the "activism" of courts, with an eventual understanding that wisdom and logic demanded the outcome. History will show that with same-sex marriage. It will show that with medically unnecessary child circumcision. The former before the latter, but the day for both will arrive.

The ABC of HIV prevention means "Always Be Cutting"?

I don't know which is more frustrating, stupid "science" articles or the reporting on those articles. Last week, my news world was filled with various regurgitations of this nonsense:

According to a new policy analysis led by researchers at the Harvard School of Public Health (HSPH) and the University of California, Berkeley, the most common HIV prevention strategies-condom promotion, HIV testing, treatment of other sexually transmitted infections (STIs), vaccine and microbicide research, and abstinence-are having a limited impact on the predominantly heterosexual epidemics found in Africa. Furthermore, some of the assumptions underlying such strategies-such as poverty or war being major causes of AIDS in Africa-are unsupported by rigorous scientific evidence. The researchers argue that two interventions currently getting less attention and resources-male circumcision and reducing multiple sexual partnerships-would have a greater impact on the AIDS pandemic and should become the cornerstone of HIV prevention efforts in the high-HIV-prevalence parts of Africa.

Hold off on assessing the validity of such claims. Wouldn't it be appropriate if they put the two key words - voluntary, adult - in front of male circumcision? That's all that the studies being cited as gospel looked at. The press release does later invoke voluntary, so I wonder if the omission of adult implies that children consent. Perhaps a look back at past writings from one of the studies authors, Daniel Halperin, might reveal anything:

As Holbrooke noted, circumcision has indisputably been proven to prevent HIV. It reduces the risk of male infection during intercourse by at least 60 percent and, unlike a condom, cannot be forgotten during a moment of passion. Nearly all of 15 studies conducted throughout Africa found that most uncircumcised men would want the service if it were affordable and safe, and even more women prefer it for their partners and children.

Excerpted from Halperin's essay referenced in my original entry.

How convenient. Even more women prefer it for their partners and children. Regarding the former, I don't care what influences or reasons adult males use if the decision to undergo circumcision is voluntary. But with the latter, that simply isn't the case. And how is it sexually relevant to (male) children what their mothers prefer regarding their genitals? (Also notice how nearly all of the studies revealed that most intact males would want circumcision. Contradictory evidence is still evidence.) Obviously I don't come to this report with any pre-established respect for circumcision promoter Daniel Halperin. But continuing from the new article.

The AIDS pandemic continues to devastate some populations worldwide. In most countries, HIV transmission remains concentrated among sex workers, men who have sex with men and/or injecting drug users and their sexual partners. In some parts of Africa, HIV has jumped outside these high-risk groups, creating "generalized" epidemics spread mainly among people who are having multiple and typically "concurrent" (overlapping, longer-term) sexual relationships. In nine countries in southern Africa, more than 12% of adults are infected with HIV.
...

For example, condom use is widely promoted as an HIV prevention measure and is effective in countries such as Thailand, where the epidemic is spread primarily through sex work. However, studies have found no evidence that condom use has played a primary role in HIV decline in generalized, primarily heterosexual epidemics, such as those in southern Africa, the authors note. This is mainly because most HIV transmission there occurs in more regular sexual relationships, in which achieving consistent condom use has proved extremely difficult.

I want to pound my head on my desk until I can't think any more. Where HIV transmission occurs, it occurs because the couple is engaging in unprotected sex where one partner is HIV-positive. If a condom is not used, that is not an indictment on condoms as a prevention technique. It's not even about condom use in a relationship. It's obviously about unsafe promiscuity. It does not take a genius to figure out that, if behavior remains consistently immune to logic, circumcision will not matter. HIV will spread. The only potential difference under discussion is the rate at which the disease spreads. Have unsafe sex with HIV-positive partners and you will become infected. It may take an extra encounter, but it will occur.

Circumcision also has the potential to encourage "just this once" disregard for safe sex practices. "I'm circumcised, so just this once, I'll ignore the condom." How many times will be "just this once"?

Under this focus on the rate, though, the true implication becomes clear. This is best shown in the poor reporting regurgitation of articles like this. For example:

In western Africa, were male circumcision is high for cultural and religious reasons, the prevalence of HIV is low and controlled trials have shown that the operation can stem the rate of infection, said Professor Malcolm Potts, of the University of California, Berkeley. "It is tragic that we did not act on male circumcision in 2000, when the evidence was already very compelling," he said. "Large numbers of people will die as a result of this error."

Because we didn't implement mass circumcision of males in Africa, large numbers of people will die. As opposed to saying that, because many individuals¹ aren't engaging in safe sex practices, large numbers of people will die? Which is more accurate at portraying a direct cause? Which advocates speculation that can't be verified? Which is scientific?

Individual actions matter. If We™ are going to intervene, we must provide nothing more than the tools for individuals to choose for themselves. Where individuals ignore known risks and engage in dangerous behavior, there will be consequences. Suggesting that we shift from truly voluntary prevention techniques such as ABC (Abstinence, Be Faithful, Condoms) and voluntary, adult male circumcision to involuntary male child circumcision is little more than an indication that We will save Them. Because They do not partake of the known methods to protect themselves as individuals, we must do it for them.

Of course, there's the giant elephant in the room. "Reducing multiple sexual partnerships" sounds a lot like Be Faithful. So we're left with only one different approach the authors believe should receive more funding. New articles and studies like this always have the goal² of pushing mass male circumcision, voluntary and involuntary, adult and child. Always.³

¹ I know that the issues of consent in sexual relations are more complicated than assuming every sexual encounter is voluntary and free from any pressure. Conceded. But that does not change the point that involuntary circumcision is not an answer to this problem. Correcting a wrong with a wrong is not valid. Individuals have rights, not collective groups.

² If you look at what the article is saying, you'll also note that the validity of ABC instead of a collectivist, utilitarian perspective on male circumcision applies to the United States. Our HIV problem is not caused by what circumcision is supposed to protect against. That hasn't stopped circumcision advocates from promoting (infant) male circumcision in the United States as a way to reduce the risk of female-to-male HIV transmission.

³ It would require its own blog entry, but I don't think any of this is some mass conspiracy by any group or profession. A mindset closed to a full set of facts, maybe, but not groups. Still, the point remains: it's always about circumcision first, even if the stated justification is "public" health or some other goal perceived to be noble.

There is one outcome that can't be corrected.

Heartland Regional Medical Center in Marion, Illinois had a problem recently where two babies were mixed up after being circumcised. Both sets of parents consented to violating their sons, so there wasn't much to blog about beyond the obvious point that no one should be surprised at any incompetence found in a hospital that routinely performs unnecessary surgery on the genitals of healthy male children. That alone is sufficient proof of incompetence.

Still, the hospital felt the need to implement solutions to prevent the mistaken identity. If you're going to violate a child, you should do it as few times as possible, I suppose. Part of the solution:

  • Only one baby, one doctor and one circumcision at a time. ...
  • The RN whose mother/baby couplet requires a circumcision will be the same RN who does the time out, accompanies the baby to the surgery and assists the physician with the surgery. That RN is also responsible for band verification and the time out.

Concerning operating room policies, Lang said surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care.
...

Thirty circumcisions a month will be observed for the next four months to insure time outs are performed according to the hospital's policy and procedure.

Concerning patients' rights, Lang stated that the patient has the right to receive care in a safe setting.

All that attention, and the only concern for the actual patient's rights is that the patient has the right to receive care in a safe setting. How about the more fundamental right to receive "care" only when it's medically necessary and indicated? Is that not a right? Would it be okay to amputate a child's arms, as long as it's done in a safe setting? Have rights really regressed to the point that we view a clean scalpel as the ceiling of a patient's rights?

May 07, 2008

Rights, Science, Tradition. Not Tradition, Science, Rights.

Last week I wrote about baby tossing, making a comparison to infant male circumcision. Today, via Kevin, M.D., here's a story that includes a debate among doctors.

"Of course there is risk of injury in this practice. Missing the stretched cloth might be fatal and even landing on it wrong might cause a limb fracture," said Dr. Joseph R. Zanga, past president of the American Academy of Pediatrics and a professor at the Brody School of Medicine, Greenville, N.C.

Objectively identifiable risk for a subjective, perceived benefit. End of discussion. Yet:

"I would not suggest that we try it in the U.S., but if they have been doing it for 500 years without any injury I'd be wary of stopping them," Zanga said.

When faced with a tradition of stupidity, it's best to focus on the stupidity, not the tradition. Science over superstition.

Dr. Michael Wasserman, of the Ochsner Health System in New Orleans, felt the same pull toward cultural sensitivity. "It is hard for one to disagree with religious rituals, as they are private choices, at the same time, there is a real danger?" Wasserman said.

This is not about disagreeing with religious rituals. If people want to toss themselves over a building's edge in a "controlled" manner, have at it. This is not that. This is people intentionally endangering another person - a child - for no objective gain to the person being tossed. Jumping and being tossed are quite distinct. The former is a ritual. The latter is madness.

However, some doctors thought the health risks trumped cultural sensitivity in this case.

"The idea that parents would participate in such a harmful practice and that no one would point out the dangers to them seems inconceivable," said Dr. Astrid Heppenstall Heger, professor of clinical pediatrics and executive director of the Violence Intervention Program at the University of Southern California, Los Angeles.

While this sentiment is based in logic, it's not really inconceivable. American parents participate in a harmful practice that disregards risk in favor of cultural sensitivity more than one million times each year. The parents have "rights", you know. As long as the tosser¹ finds value in the act, the tossed is merely the necessary pawn assumed to value the subjective gain more than the objective risk. He or she² isn't completely worthy of individual protection because the group finds some benefit.

¹ No derogatory pun intended.

² Except for genital cutting, of course. There the comparison allegedly breaks down. Cutting healthy boys is valid tradition, but cutting healthy girls, that's barbaric, even when it's tradition. Half of that rationale is wrong. Would doctors suggest it's okay to toss only male children from a building?

May 05, 2008

Examples of "(male) children as chattel"

I don't generally listen to what parents claim when they circumcise their sons. By nature of the act, they treat their son's body as their property. They would deny it if confronted with this logic, and most aren't willing to listen to even that. It's mostly fruitless fodder for philosophical discussions.

Sometimes, though, parents come out and make it nakedly obvious. From this thread on cloth diapering after a circumcision, which descended into defensiveness and ad hominem. (To be fair, the original question asked for an answer independent of whether to circumcise or not.) Select quotes:

# 10: first off, ignore any "hate responses" as you are the parent and it is YOUR choice. Don't listen to scare tactics. ...

YOUR choice. Also, only those opposed to circumcising non-consenting, healthy children can use scare tactics, of course. A focus on HIV, UTI, penile cancer, STDs, hygiene, and social rejection aren't fear-based tactics?

# 19: ... What ever choice you make mamma is the right one. It is your son and your choice [sic]

There can be no objective truth, as long parents wish hard enough with good intentions.

# 37: ... Dont [sic] worry about the anticirc posts, he's your baby, it's your decision. ...

She's your baby, it's your decision? Nope.

I expect every single mother quoted here would deny that their words mean they consider their sons their property. But the logic just doesn't hold up. It's always the self-absorbed obsession with how circumcising affects them, without consideration for the how it affects the boy negatively or what objections he might one day raise. It's their (capitalized for emphasis) decision.

This is interesting to me since I've encountered the hysteria that arises the moment anyone hints at a comparison of performing genital surgery on female minors. No woman would want that done to her. Duh. But every boy will be perfectly content if it's done to him. He'll applaud his parents. Again, duh. Except I can't figure out how to get from "medically unnecessary" to "duh", intellectually or emotionally. It will never compute because it requires willful ignorance.

**********

For fun, here are two comments in response to the links offering information against the circumcision of children:

# 15: ... she [sic] asked for ADVICE on CARING for an INFANT, not if you thought the reason behind that special care was/is warranted. ...

And:

# 27: And that pertains to cloth diapering after a circ how? ...

The links pertain to cloth diapering because, at its core, if you don't engage in a surgical violation of the healthy boy's body, the debate over what to do to protect his sensitive penis is moot because nature's already provided the protection. If you ask me what's the best way to diaper a girl whose parents surgically altered her healthy genitals, I'm going to question the validity of the action that makes the question allegedly defensible. There is no difference because the cutting occurs on a penis rather than labia or a clitoris. None.

Throwing a Scalpeled Hail Mary.

Do unto others, or something like that:

During spring break, [University of Florida quarterback Tim] Tebow added a new facet to his fame. In an impoverished village outside General Santos City in the Philippines, Tebow helped circumcise impoverished children.
...

"The first time, it was nerve-racking," he said. "Hands were shaking a little bit. I mean, I'm cutting somebody. You can't do those kinds of things in the United States. But those people really needed the surgeries. We needed to help them."
...

Others saw [Richard] Moleno, who after a crash course from the Filipino professionals, circumcised 10 boys and removed six cysts, some the size of tennis balls. Tebow helped with the last few circumcisions, growing more comfortable with each one.

"I got a kick watching him," [Tim's father] Bob Tebow said. "He did a great job, and he didn't look really nervous. I wouldn't let him cut on me, but he did well and helped where there was a need."

Before I comment, circumcision in the Philippines is generally not like what we think of as circumcision. It is more an opening up of the foreskin through a dorsal slit than anything. It's also a ritualistic transition from childhood to manhood, although it's still forced on children. And the social pressure to circumcise is even more intense than it is in the United States.

Also, I have no idea if the boys in this story needed circumcision or not. I assume they didn't, but the conditions they live in don't exactly suggest that as an obvious assumption. The number of child circumcisions suggests, though, that there was more of a ritualistic "need" than a medical need. Obviously I oppose the former entirely, with condemnation for the latter only when less invasive treatments are ignored when treating a child.

To the story... This is something to joke about? "I wouldn't let him cut on me...", but it's acceptable to cut on a child? One doesn't have to grasp the ethical problem with the medically unnecessary circumcision of children to grasp that competence gained through extensive education should be a prerequisite for performing any surgery. There is a reason we won't allow it in the United States. There are actual human - with rights - beings involved. Complications occur. What would someone have said if Tebow had made a mistake? Not that this story implies Tebow performed flawlessly on these people, but would an accidental amputation of the glans earned anything more than an "oops"?

I like to run with my intellectual curiosity, like most people. Yet, I'm capable of understanding that getting my jollies should still recognize the rights of others.

May 02, 2008

Is this a parental right?

Via Boing Boing, I thought baby dropping had to be a hoax.

Muslims in western India have been observing a bizarre ritual - they've been throwing their young children off a tall building to improve their health.

The faithful have been observing the ritual at a shrine in Solapur, in western India's Maharastra, for more than five hundred years.

They believe it will make their children strong and say no accidents have ever happened.

The video accompanying the article suggests it is not a hoax, although I remain skeptical. But it does raise an obvious question. Is this a parental right similar to the claimed right to circumcise male - and only - male children? The child doesn't need to be tossed from a building. There is an objectively identifiable, if hard to quantify, risk of injury, both minor and severe. There are benefits stated by parents that are subjectively identifiable, objectively unprovable for the child being tossed, and hardly guaranteed to be preferred by the child as an adult. Would he or she choose, as an adult, to be dropped from a building into a sheet below? (Note: The one child whose face we see closely in the video appears to be rather not enjoying the process.)

Compared to infant (male) circumcision, should baby dropping be treated ethically and legally different?

Don't let the crazies get something more right than you.

It's pretty pathetic when Conservapedia is more accurate on female genital mutilation (link) than most other Internet debate on the topic.

The procedure may range from a simple cut in the pubic region to the complete removal of parts of the female reproductive organs.

There's very little else there, and there's no source for the specific claim. (That could be here, as an example.) But it's accurate, in a simplistic way that's almost always missed.

Unfortunately, that sentence follows a statement that's inaccurate because it's partially refuted by the statement above.

Female circumcision, practiced in parts of Africa, is a much different procedure that can have lasting effects on a girl's health.

That's all there is. It's not possible to argue the accurate claim that a form of FGM involves only a simple cut and still adhere to a claim that male genital mutilation is a "much different procedure". I'm sure many would defend this by going into intent. I don't accept that because the claim that FGM is strictly imposed to eliminate the ability to feel sexual pleasure is often wrong. There's also the core human right to remain free from harm. Genital cutting on a healthy individual without the individual's consent is wrong. It's ethically and legally incorrect to discriminate in judgment against this practice based on gender.

Not that the UN and World Health Organization understand this core stance. WHO defines gender discrimination in its glossary:

Gender discrimination refers to any distinction, exclusion or restriction made on the basis of socially constructed gender roles and norms which prevents a person from enjoying full human rights.

There's the irrelevant claim that women prefer circumcised partners. There's the more vehement dismissal of any (equally irrelevant) claim that men in certain cultures prefer women with surgically altered genitals. Etc. etc. (c.f. this entry.)

**********

Lest you think I give any actual credibility to Conservapedia, I quote this statement from the circumcision entry:

The procedure lasts only ten minutes and ...

No source supports that statement in the entry's footnotes. If, as the site's About page suggests, this is the sort of thinking meant "to educate advanced, college-bound homeschoolers", my low opinion of the site should be obvious.

April 28, 2008

A Hypothetical Argument Against Tradition

A common defense used to justify continued legal indifference to the clear rights violation of male child circumcision in the United States is tradition. The sometimes-blurry distinction between ritual and social tradition is mostly irrelevant. The argument is that humans have been circumcising male children for thousands of years. In the United States, the tradition approaches 150 years. Tradition relies on "if it ain't broke" without questioning whether or not it's broken. I reject this, obviously, but I'd like to offer a hypothetical scenario:

A family gathers every Thanksgiving at the home of the family matriarch. This has continued for decades, and now includes children, grandchildren and a few great-grandchildren. Every year, the menu remains constant. The festivities start at the same time. Afterwards, there's football in the yard before watching football on television.

One family member does not participate because he chooses to spend the holiday at with his wife's family.

Those who defend tradition seem to argue that an opposition to male child circumcision rejects this. Reject tradition-inspired circumcision and you reject a family's ability to decide. This is not the case, because the correct equivalent includes one additional piece of information not yet expressed in the hypothetical.

The man who chooses not to participate is physically forced by his blood relatives and barred from leaving the family's holiday celebration. When he objects, he is restrained. At the end of the festivities each year, he is permitted to leave.

If he sought state intervention, would he have a valid claim of false imprisonment? Does the family's claim of tradition supersede his right to be free in his movements and activities? The answers are undeniably "yes" and "no", respectively.

Obviously the age of the individuals is an essential variant in the discussion. Let's consider it. If the family refused to circumcise a son in childhood, when do they lose the right to circumcise him? At age 18? If at 18, is it not contradictory to permit them to circumcise him without need before that age? In doing so, they are effectively granted the right to choose circumcision for him at 18, 28, 38, 48, etc. He can't unchoose what they've imposed. The permanence of the decision separates it from every other parental responsibility claimed as an equivalent. Those alternate claims involve life-sustaining needs (food) and/or objective benefits (education). Circumcision fits neither category, while also lacking the affected individual's ability to overcome poor choices by his parents contained in legitimate choices based in parental responsibility.

That returns the defense to tradition. Children may be forced to attend the family gathering for Thanksgiving. Conceded. But the logic - defined loosely - needed for forced circumcision of minors based on tradition requires a familial right to override an adult's liberty to refuse attendance at all present and future gatherings. No such right exists. There can be no consistent rule based on tradition. Thus, tradition can't be an acceptable defense for a permanent reduction of another's future bodily choice, barring objective medical need. We must rely on principles rather than tradition. Principles center exclusively on the individual and his natural rights.

April 26, 2008

Equality means equal suffering?

One more for today (and one more for tomorrow, then there will likely be a lull in the circumcision posts). In a comment to this anti-circumcision essay, commenter "MizMoxie" wrote this:

... I would have sex with anyone with one not "cut". [sic somewhere in there, as you'll see] Too much waste and bacteria and gunk. Yuck. Besides, women have to go through a bunch just because we are women. I personally think that a male child should have to suffer a little. I've never heard a grown man say he remembers the pain of his circumcision! ...

I hope that's meant as a lame effort at humor. I've encountered that argument in the past, so I don't think it is. I assume it's real, if only for my purpose here. When dismissing principle in favor of subjective defenses like tradition and fear, this will occur. The law currently permits this justification as much as any other, even though the intent is clearly harm (among multiple poor excuses) to the child.

Is permitting harm to male children to balance the harm females suffer a legitimate trade-off to protect the perceived rights of parents to decide what is anatomically in the best interest of their children sons? If not, what is the consistent, objective rule of law to prevent this harm that doesn't also prevent "good" reasons (that still lack medical need)?

Sanity on the Limitation of Parental "Rights"

A few days ago, in the context of the current FLDS story, Timothy Sandefur posted a principled defense of children and their rights against the (religious) claims of their parents. It's very similar to what I've written about circumcision generally, and ritual circumcision specifically. The parents' religion is not enough to justify the objective harm under civil law, regardless of the sanctity and tradition of the action. Still, Mr. Sandefur's wonderfully stated words are worth posting here. (Note: I have no idea whether he would apply this to the medically unnecessary circumcision of minors. I suspect he does, but I do not know.)

The starting point of the analysis must be the principle that children have rights valid against parents, including the right not to be raised in an abusive or neglectful environment. The state has the legitimate authority to enforce these rights against parents. The state obviously has the legitimate power to take a child away from parents who beat him, or from a family of homeless alcoholics who neglect him. The fact that parents act abusively or negligently because they believe that God wants them to does not change the analysis. It cannot change the analysis, because it would, of course, create an easy route around laws that validly protect the rights of children: just assert that abuse is part of your religion. Heaven knows that’s been tried many, many times.

We do not allow parents to beat their children, yet that almost always leaves no permanent physical damage, unlike circumcision. Of course the psychological damage of physical abuse is undeniable. But is parental intent really enough, which is what seemingly allows circumcision while prohibiting other abuse? (cf. this post) Since one excuse used in favor of infant circumcision is that the boy won't remember it, I say no. If a parent punches an infant, the infant will not remember it. But the act itself, separate from other considerations, is antithetical to the child's individual rights. The motivating intent we assume (or discover) of the parent is irrelevant. As Mr. Sandefur's statement declares, we shouldn't excuse abuse just because parents claim God made them do it.

Mr. Sandefur continues:

... —and the state has the legitimate authority to defend that right [not to be imprisoned in an asylum], again, within certain (often vague) boundaries set by a parent’s right to direct the upbringing of a child. The latter right, however, must yield to a child’s objective welfare. In other words, while a parent has broad discretion to direct the education and upbringing of a child, that discretion exists within boundaries which the state may police, and keeping children away from education, medicine, &c., are things which—at least at some level—exceed those boundaries. ...

The surgical alteration of a healthy child's genitals exceeds those boundaries. We already recognize this for female minors. The Female Genital Mutilation Act explicitly denies parents the option to cut their daughters for non-medical reasons. The 14th Amendment, among other Constitutional claims, implicitly requires us to prohibit genital mutilation of male minors.

Perhaps more succinctly, Mr. Sandefur clarifies his point in a follow-up to his original post. Discussing the implications of two court cases, Yoder and Pierce, and the constitutional limits imposed on parents, he writes:

... The fact that some communities claim that God wants them to abuse or neglect children is just not a good reason for allowing them to do so, and the state is and ought to be more concerned with ensuring that children’s rights are protected than with whatever excuses parents give—mystical or otherwise—for violating those rights or for neglecting those children. ...

I can make no comment on the validity of his legal analysis; I am not an attorney. But his reasoning is logical and based in individual liberty. The family is not society's building block, with parents acting as property holders of their (male) children until the children reach the age of majority. What's in the best interest of the family is collectivist, anti-liberty nonsense. Cutting is objective harm. The absence of medical need demonstrates that there is no corresponding objective benefit to be gained that would permit a discussion of parental proxy after applying the child's individual rights. So, while I certainly adhere to a libertarian deference to parents and a suspicion of extraneous laws, legislatively prohibiting medically unnecessary genital surgery on minors is well within a libertarian framework of appropriate and necessary state use of power.

It would be nice if we didn't have to do this. Maybe we can even justify not having a specific law prior to the beginning of child circumcision, if we lived in an alternate world without the historical tradition preceding the United States. (Assault laws would still be applicable, I think.) But approximately 3,000 male minors have their healthy genitals surgically altered every day in America. Rights are being violated. Not only may the state intervene, the state must intervene.

Caveat: I am not claiming that religious circumcision of minors proves the religion is harmful. I am claiming that religious circumcision of minors is a blind spot against individual rights that can't be overcome through claims of parental "rights". This must be prohibited in civil law. Civil law applied to the individual must trump any and all concerns of religion, particularly since the to-be-circumcised individual retains his own freedom of - and from - religion. He alone must decide if he wishes to express his faith in this manner.

Can protection be harm?

Via A Stitch in Haste, ABC News ran a social experiment in two cities, Verona, N.J. and Birmingham, Ala.

Two years ago, ABC News hired two actors, a man and a woman, to publicly display their affection for each other by kissing in public at a restaurant. Reactions from other restaurant-goers varied; some onlookers enjoyed the sight of young love, while others lost their appetite.

This year, we once again decided to explore how the public responds to public displays of affection -- but this time, our couples were gay.

911 "hilarity" ensued in Birmingham, as Kip highlighted. Shameful, but not my point here. Instead, this:

... A topic that did come up repeatedly was children. "I don't really find it inappropriate, especially during the day when schoolchildren aren't running around. They might get confused and want an answer for what's going on," bystander Mary-Kate told us. The majority of the people who spoke about children seemed to echo Mary-Kate's feelings. They are indifferent to gay PDA but did not want to, or know how to, address homosexuality with children.

People wilt under the pressure of addressing "tough" issues with children. (Some to a greater extent than others.) But when children get confused and want an answer for what's going on in the world, the proper response is to treat them like human beings who deserve respect. Adults must apply tests to decide what information is appropriate to censor or finesse, but shielding children from information solely because the question makes the adult uncomfortable is not a rational response to reality.

Obviously I'm drawing a comparison to circumcision, so I'm not going to dance around the topic. When I've protested on the lawn of the U.S. Capitol against infant male circumcision¹, children approach to discuss the topic. I discriminate based on age. Without a good qualifier, it's best to let the child ask. This generally leads to self-selection among the children who are capable of understanding and discussing. The youngest child I've spoken to is probably 10 or 11. And I still limit the discussion away from the anatomical function of the foreskin during intercourse and masturbation. However, those children are capable of understanding the core of the issue. They know when they're being lied to. I've witnessed parents offering excuses to children while shielding them from any consideration. The children rejected these excuses by asking further questions.

I'm dismayed at how many people, even when not rejecting that same-sex relationships exist, fear that children can't understand love if it's not packaged in a specific, safe manner. Safe, of course, refers to the perceptions of the adult, not the child.

¹ Here's a writing tip for you. The first edit of the footnoted sentence read:

When I've protested against infant male circumcision on the lawn of the U.S. Capitol ...

There are no circumcisions occurring on the lawn of the U.S. Capitol, to my knowledge. Clarity demands that the writer group "on the lawn" with what occurred on the lawn.

April 24, 2008

The U.S. owes the world. The world owes nothing to individuals.

Here's an interview (part 2 of 3) with Stephen Lewis¹, a former diplomat now involved in HIV/AIDS issues. Here are a few curious excerpts (italics added):

What do you think should be done [to fix PEPFAR]?

People should demand more – much more. No one denies that when you pump several billion dollars into a response it will mean something. Of course it will; millions of people will be treated. That's terribly important.

But that's what we deserve to expect from the United States. You don't kneel down before a country because it's doing… something that the world has a right to receive. The American administration is so discredited, George Bush is such a lamentable president, that when anything of a positive kind happens people are prostrate at the unlikelihood of it and they shouldn't be.

It gets worse from there, but it's most important to focus on the key assumption. The world has a right to receive American funding for its problems. I'd like to know the socialist theory Lewis is using to arrive at the conclusion. Presumably we're only allowed to call our giving "charity" if we need to feed our American egos. The world will acquiesce with that concession, but the dollars must continue to roll in to satisfy the world's right to receive.

I don't have anything else nice to say about that, so I'll move on to the next interesting bit. (Again, italics added.)

How about the response of the United Nations to HIV/Aids in Africa?

There is just so much more to be done. Frankly, one of the things that is inadequate is the United Nations agencies. Some of it is bewildering.

For example, you get the Minister of Health in South Africa (Dr. Manto Tshababala-Msimang [sic]) attacking and dismissing circumcision as a preventive technology. Here you have three determinative studies, definitive studies, we have UNAIDS and WHO encouraging male circumcision as a way of reducing transmission and you get an attack on it by the minister of health in South Africa. Where is the United Nations' voice? Why haven't they taken on the minister? Why haven't they said what should be said, which is that she's effectively dooming people to death and it need not be done? You have to have a much stronger voice of advocacy from the United Nations in dealing with disease and related matters.

Dr. Manto Tshabalala-Msimang is nuts is HIV, yes, but Lewis' rant against the United Nations is bizarre. Whether it's pushing circumcision through UNAIDS with breathless calls-to-action, issuing press releases touting the latest hype on the original story from WHO, or endorsing gender-based human rights violations through its remaining organizational reach, I'm not sure it's possible to do more for the organization to insert its reach any further into this debate on the wrong side of human rights. But that's defensible. Instead, let's complain that they never criticized Dr. Tshabalala-Msimang for being stupid and dangerous.

Except, they did.

The United Nations special envoy for Aids in Africa has closed a major conference on the disease with a sharp critique of South Africa's government.

Speaking at the end of the week-long gathering in Toronto, Canada, Stephen Lewis said South Africa promoted a "lunatic fringe" attitude to HIV/Aids.

Mr Lewis described the government as "obtuse, dilatory and negligent about rolling out treatment".

Hey, wait a minute. Stephen Lewis? Stephen Lewis, working as special envoy for AIDS in Africa, attacked Dr. Tshabalala-Msimang's comments in August 2006. Denouncing idiotic statements is necessary, but move on. Leave the grudge match to the WWE. Instead, every microphone is dead horse meets Stephen Lewis' stick.

I did thoroughly enjoy this, in an "I'm disgusted" way:

"It really is distressing when the coercive apparatus of the state is brought against the most principled members of society," he said.

Clearly Lewis is exhibiting a textbook case of Kip's Law. I would challenge Lewis' assertion that he is principled, since the UN's Declaration of the Rights of the Child clearly forbids medically unnecessary genital cutting, without exceptions for gender or potential disease prevention. Nor am I particularly moved by his claim of oppression. Are infants subjected a coercive apparatus when they are circumcised, in part based on the rantings of individuals like Stephen Lewis?

¹ The following biography accompanies the article:

Formerly the special envoy for HIV/Aids in Africa for United Nations Secretary-General Kofi Annan, [Stephen Lewis] is now chairman of the board of the Canada-based Stephen Lewis Foundation, which endeavors to ease the pain of HIV/Aids in Africa by funding grassroots projects. Lewis is also co-director of Aids-Free World, a new international Aids advocacy organization based in the United States.

This will be important later in the entry.

With advocacy like this, who needs enemies?

Advocates for Youth is

... dedicated to creating programs and advocating for policies that help young people make informed and responsible decisions about their reproductive and sexual health. Advocates provides information, training, and strategic assistance to youth-serving organizations, policy makers, youth activists, and the media in the United States and the developing world.

Helping young people make informed and responsible decisions about their reproductive and sexual health is a noble goal. This is not that:

  • Human rights—Planners must take an approach to offering male circumcision that acknowledges the human rights of the client:
    • Every adult male who is considering circumcision for himself should be able to give informed consent.[1]
    • Where a minor is the prospective client, counselors must take extra time to ensure that the minor and his parents understand the procedure and that the young male consents to it.[1]
    • When an infant is to undergo the procedure, his parents must be fully informed.

If he is an adult, the male must consent. If he is young, the male must consent. If he is an infant, no human rights principles apply to him. That is a pathetic view of human rights. Anyone who accepts that view is not an advocate. At best, he is a propagandist who does not believe in principles, only principals who may act on another according to an undefined criterion.

What is the delimiter indicating when a male ages out of "pre-young" and into young, conferring a human rights requirement for consent before his healthy genitals may be surgically altered? I reject the answer in advance for reasons I've explained in detail. Still, I want to know because I do not understand the magical powers wrapped around the penis that reduces mankind's ability to think when applying principles to its anatomical sanctity. So, advocates of the "pre-young" qualifier within human rights, when do "pre-young" males get the (ahem) equal right to consent - or refuse consent - to the surgical alteration of their healthy genitals that young and adult males possess?

Post Script: The footnote attached to the young and adult requirements points to an excuse from the usual suspects in infant male genital cutting advocacy. I will not provide a link to that report here.

Post Post Script: I addressed a similar, gender-based ethical lapse in a previous entry challenging nonsense from UNAIDS.

Consent plays a role, too.

This article on adult circumcision was the companion piece to the recent Los Angeles Times article on infant circumcision. It would've been easy and proper to focus on consent, here and in the article on infants, but instead it's mostly fluff seemingly intended to prove that men really, really like circumcision. The facts don't support the article's implications, although you have to know the facts because they weren't provided in the article. I suspect this is mostly because the reporter lazily relied on urologists, who will inevitably see only men with an issue. Healthy, happy intact men don't generally visit a doctor to say everything's fine.

Still, I found one useful nugget (emphasis added):

Dr. David Cornell, a urologist who runs the Circumcision Center in Atlanta, sees men who want a circumcision because they prefer the appearance and because they want to feel more comfortable socially.

"I hear a thousand times a year from men who don't feel that they look like most other men in the locker room. In our society, there's an overriding preference for circumcision," says Cornell, who performs 250 procedures a year on men who, for cosmetic reasons, want a circumcision or a revision to one they don't think looks right.

Even where the male eventually agrees with his parents and/or society's subjective judgment that circumcision is more aesthetically appealing, what is specifically appealing is also subjective. Dr. Cornell surgically alters (consenting¹) circumcised men toward the body they want. This part of his practice demonstrates that even when parents guess correctly, there is no guarantee that this will be sufficient.

Of course, men could also choose this if left intact, with a better chance of getting exactly what they want² because they have everything to work with, rather than the remnants of the original circumcision.

¹ Also from the article:

Though frequently attacked by anti-circumcision activists, [Dr. Cornell] says, "I'm doing a cosmetic operation on a consenting adult. Why he's doing it is his business."

He's correct. Those activists damage the legitimacy in this debate. Circumcision is only the expression of the real issue, the lack of consent from healthy minors whose genitals are surgically altered.

² Or what they think they want. I know at least one man whose parents did not circumcise him. He chose it for himself as an adult to conform to societal expectations. He hates the results and regrets his action.

April 23, 2008

Surgery as a Replacement for Parenting

I used to feel some reservation about quoting parents when they've said something stupid about circumcision. You've probably figured out that I shed that a long time ago. When someone says something stupid to a reporter, I highlight it solely to point out that people are using stupidity to justify imposing permanent, medically unnecessary surgery on their child. (Doctors are complicit in this nonsense, which will also be obvious.) From an article out of St. Louis:

"I tell people there's not a real medical reason for them to have [ed. note: Have? Force.] a circumcision," said Dr. Jack Klein, chief of obstetrics at Missouri Baptist Medical Center, where 1,873 of the 2,144 boys born in 2007 were circumcised. "I will tell you the majority reason that people get circumcised is because they want their kid to look like other kids."

That social conformity is reason enough, say some parents concerned about future locker room comparisons and sexual relationships.

"I really didn't want to be faced with a teenage boy asking me why I didn't do this and not have a really good reason for him," St. Louis resident Amy Zimmerman said of her 2-year-old son John.

Notice who she is concerned about. Her concern was about her own feelings, her own desire to avoid the potential for (allegedly) tough questions from her son. That was enough for her to justify unneeded surgery on her son. She seems to wish to parent her son only in ways that do not exceed her level of comfort with potential issues. If it might be uncomfortable for her, her fear is enough to dismiss the healthy, intact (i.e. normal) individual he was, as well as the preference he may one day hold for having his genitals intact. Ms. Zimmerman fails to understand what it means to "not have a really good reason".

Not that he would've complained if she didn't have him circumcised. That's speculation. But even if he would eventually complain, it's an easy position for parents to say "We didn't cut your healthy penis because it was healthy." That's rather simple. If he's not placated by that, it would still have been possible for him to choose circumcision. But if she's faced with a teenage boy asking why she did this, and he is not happy about it, what then? Oops?

If an individual does not want to parent his or her children, that person should not have children. Cosmetic surgery on healthy children to avoid future questions is a coward's solution.

**********

Unfortunately, doctors are complicit in this abdication of parenting. Dr. Klein's statement above makes this clear, since the surgery is objectively not indicated. But they cede this point in the name of parenting, a very poor conception of that responsibility.

Ultimately, it's a personal decision, said Dr. Joseph Kahn, chief of pediatrics at St. John's Mercy Medical Center.

"Like every decision for every surgery on every child," he said, "it really needs to be something that's discussed with the parents."

Ultimately, we don't treat it as a personal decision. The male choosing or rejecting circumcision for himself would be a personal decision. And like every other decision for every other surgery on every female and male child, it really needs to be something that's medically necessary. That's the first principle that's ignored. Or can parents just order any cosmetic surgery for their child son(s)?

Female genital cutting is prohibited, of course, regardless of the "personal decision" parents might wish to make. We don't listen to nonsense about parents deciding what's best for their family, the newest mantra I see developing around male genital cutting. What's best for your family, when you decide to have a family, is that each person's bodily integrity is respected. You decide to have children. When they arrive healthy, you do not then have a special veto power over the form of that child's body just because he is a he and not a she.

Where medical need is absent, intervention is illegitimate.

April 22, 2008

"Just a 'little' off the top" is subjective.

In an essay discussing a magazine article reviewing the origin of circumcision, the author demonstrates - parenthetically - why it continues.

(The most logical explanation is simple. The male organ [sic] simply looks better post-circumcision than it does pre-circumcision. And looks matter: Consider how visual an animal the human male is and just how much time he spends gazing at himself.)

That's not logic. That's a subjective preference rationalized from an ex post facto analysis fueled by cultural conditioning, as well as a refusal to accept that what is common is not necessarily normal and may, in fact, be harmful.

(For my own parenthetical, the last sentence of the excerpt warrants a response, but it is beyond the scope of my more fundamental argument. If you understand my objection to the first two sentences, my critique of the third sentence is obvious.)

Then, this:

I put the magazine back on the stack, fishing for my handkerchief to deal with the chilly sweat now covering my forehead. [ed. note: There is slightly more context to this excerpt, before and after, but excluding it does not alter the meaning.]

I will never understand how circumcised men react to discussion of the topic this way, only to defend imposing on infant boys what would be so objectionable to them now. What makes a man express relief because he doesn't remember rather than disbelief that something so objectively offensive could be forced on him? And where is the empathy, the moment of thought for other individuals that might make us ask whether or not he wants his healthy penis cut?

April 21, 2008

This "flexible and compassionate" is misdirected.

This article appeared in the Boston Globe last week. It's a discussion of efforts to train new mohels in Massachusetts. Two particular passages are relevant to my focus. First:

Be flexible and compassionate, [Dr. Bob] Levenson told the doctors. ... Gently tell the truth when a tearful, post-partum mother asks if babies can feel pain. (The answer is "yes, but I'll be as quick as possible"). And it is perfectly OK - recommended, even - to anesthetize the infant with a little kosher wine dabbed on the lips.

Beyond wanting to see evidence that wine dabbed on the lips of an infant male will anesthetize him from the pain of surgery, this issue raises a large ethical red flag. There must be an objective reason to inflict pain on another, particularly a child who can't offer (his) consent. And does the infant male's soon-to-be-removed foreskin serve a purpose? The answer is "yes," no parenthesis necessary or appropriate.

Second:

But for doctors, the work is not considered particularly lucrative. Mohels must secure their own malpractice insurance, spend significant time counseling families, travel, perform the ceremony on the eighth day of a child's [sic - male] life, all for a fee of $350 or $400.

If a religious observation requires medical malpractice insurance, it is only legitimate to perform on consenting adults. The individual right of minors to be free from (medically unnecessary) harm must remain the exclusive standard, superior to any religious requirements, because risk is objectively inherent. The evaluation of that medically unnecessary risk against unverifiable religious benefits is subjective. The conclusion is only legitimate from the individual giving up his foreskin.

April 10, 2008

Kenyan government to roll out human rights violations.

The Kenyan government is rolling out a plan that overlooks a few key issues.

The Kenyan government has embarked on an ambitious national programme to fast track the national rollout of male circumcision as a means of preventing HIV.
...

According to the new policy document, circumcision will be rolled out for males of all ages in a culturally sensitive way and in a clinically safe setting.

I searched for the policy document but haven't been able to find it. Still, this says everything. Males of all ages. And they're more worried about culturally sensitive ways than they are about human rights or common sense. These children aren't having sex. And there are other, more important (the only?) reasons for the HIV epidemic in Kenya (italics added):

Why is there more AIDS in some parts of the country than in others?

Infection levels are generally higher in urban areas than in nearby rural areas, and some parts of western Kenya have the highest recorded rates in the country. HIV is still spreading in Kenya, so that many rural and urban areas that had low infection levels in the past are now experiencing higher infection rates. Many factors may contribute to these differences, such as high population density, more movement of people because of trading and migration routes, non-practice of circumcision, sexual networks within communities, and cultural practices such as wife-sharing and widow inheritance.

Fixing the "non-practice" of circumcision will solve nothing as long as the last two remain in practice. If, at the very least, the last two are properly compensated for with condoms, fixing the "non-practice" of circumcision will be unnecessary.

Worse, this mentality:

"Our pilot is a free mobile outreach, where a team of five members - a doctor, clinical officer, care assistant, nurse and driver - goes into various communities and sets up camp in a room at a local medical centre or in a tent, and invites people to come or bring their children for circumcision," said George Obhai, monitoring and evaluation manager at Marie Stopes Kenya.

Before the mobile team arrives, the local hospital or clinic is contacted to conduct community mobilisation, and on the day every man getting circumcised receives counselling from a trained member of staff before the procedure is carried out.

"Interestingly, many of the ideas people have about male circumcision work in our favour, even among the Luo; for example, people believe that it improves the sexual experience and that ladies prefer circumcised men," he added.

I respect the idea that moving from traditional circumcision to clinical circumcision will improve the situation for boys, however small the improvement. But to willingly embrace subjective nonsense because it works in your favor is absurd. Medical procedures on children must be based in science alone. There is medical need or there is not. Everything else is irrelevant and should be explained and disregarded as such when it appears.

This plan - as will all similar efforts around the world - will be properly seen as worthless failures when we analyze the long-term results many years from now.

**********

In somewhat related news, this bit of genius (link via by way of Male Circumcision and HIV:

It is now illegal to encourage the use of condoms in southeast Nigeria’s Anambra State. The state government has also banned the advocacy and distribution of other forms of contraceptives including IUDs (intrauterine device) and any other “un-natural” birth control.

“Instead of teaching children how to use condoms to enjoy sex they should be taught total abstinence,” the state commissioner for health, Amobi Ilika said when announcing the measures in late March at the state capital, Awka. “The use of condoms has greatly encouraged immorality,” he said.

The question of proper governmental role aside and an understanding that condoms are still available, what could possibly go wrong?

April 09, 2008

I wouldn't use the word "debate".

Following on today's earlier entry, how many pro-circumcision myths does this short essay, "The Debate Over Circumcision," inadvertently expose as flawed?

My first son had what can only be described as a bad circumcision. While he was still in diapers, the skin at the tip of his penis started to get sticky and when we changed him, we were unable to pull the skin back to do an adequate cleaning. "It's a problem," the pediatric urologist explained. I am sure there is some medical term for the condition, but all I can remember is that it required a trip to Boston's Children's Hospital where, in the office, my little boy had to get "re-snipped."

This was very, very difficult to for me watch. Despite receiving a local anesthetic, my son cried a lot. So did I. When I found out I was expecting another boy, I did more research on circumcision and stumbled across countless websites arguing both for and against the procedure. Given that my husband and I are not of the Jewish or Islamic faith, where circumcision is customary, there was no real reason to choose circumcision other than family tradition. The medical arguments don't really hold all that much weight, in my opinion.

The complications the author's son experienced are easily explained. At birth, the foreskin adheres to the glans thanks to synechia. The inner foreskin is mucosal tissue, just like the nose, mouth, and female genitals. It doesn't magically stop being mucosal tissue after circumcision. It only stops acting like mucosal tissue through years of keratinization. Until that occurs, any loose foreskin will tend to re-adhere because it is moist mucosal tissue. As the author discovered, this can require further surgical intervention. It can also lead to complications (NSFW - graphic images).

This is objective harm. Even when parents understand some of the risks - through the experience of their previously healthy sons - from medically unnecessary infant circumcision, they're willing to proceed again. The risk of it becoming reality for the boy is inherent in every infant circumcision. No one has the right to impose this risk on him without medical need. No one should have the legal option to impose this risk on him, either.

A libertarian argument for a new law.

Mark, who writes the excellent Publius Endures, left an excellent (and appreciated) comment over the weekend. Normally I would reply there, as I do with most comments. But Mark included one point that I'd like to discuss (emphasis added).

I must say that the circumcision debate (to the extent it can even be called that) has made me feel relieved that my wife and I are having a girl since we don't even have to consider the issue. Circumcision is frequently done almost without thought, essentially as a ritual. Until Andrew Sullivan started blogging about it in the last few years, it was an issue that I didn't even consider - I thought it was something that was just what was done. People like you and Sully are starting to open eyes that the practice largely lacks any kind of basis other than as a cultural norm.
The main reason to perform circumcision, as far as I can tell, is that it may create some awkwardness when the child becomes a sexually active adult. The thing is that by the time that becomes an issue, the child will be more than capable of making the decision on his own.
If we had our child a year ago (and it was a boy), I think I would have opted for circumcision just based on the fact that it is a social norm and that there is little publicity about the arguments against circumcision. Were the decision to come up now, I would almost certainly not circumcize.
I'm not sure the procedure should be made illegal, though, but only because I'm generally opposed to adding new laws. However, parents need to be better informed about the risks and generally nonexistent benefits of circumcision.

Before I respond, allow me to clarify that this is in no way meant to condescend on this (or any) point. Although I'm certain that I'm right in all facets of my approach, I've thought about this every day for many years. I've read a lot of bad arguments on both sides. Reading through them can be tiresome, and without self-monitoring, my response can fall into frustration. (I try to avoid outright disdain, even though there are places where it's richly deserved.) Mark's comment is none of that. He shows an open mind that demonstrates genuine intellectual curiousity. He grasps the fundamental argument against male infant circumcision and is willing to act based on that new knowledge. Or to not act, based on that new knowledge. I wish more people had that kind of integrity.

Nor am I suggesting that he does not understand any of the libertarian approach I advocate here. Allow me to reiterate, if you're not reading Mark's blog, add it to your RSS feed today. His libertarian credentials are well written in his entries. Here, I'm only offering how I think a libertarian approach must be applied. I've read that libertarian arguments don't apply to children. I find that strange, so this is at least tangentially a refutation of that.

To his comment, though, I think there's an easy libertarian argument that demands legal prohibition. The Female Genital Mutilation Act of 1995 exists. As long as it is valid law, restricting all medically unnecessary genital cutting on female minors, even at the request of parents, the 14th Amendment demands that the government treat citizens equally. The only choices are to repeal the FGM Act or make the law gender neutral. Since we all agree that the former is unacceptable, we're left with the latter. (Take a look at the work Matthew Hess is doing to achieve an MGM Bill.)

Beyond that, viewing government through a libertarian goal of maximizing liberty, I'm against any law that would restrict people from making that decision for himself (or herself). I can form whatever opinion I want about someone's decision, but it's irrelevant to what he should be able to do to himself. Weigh the benefits against the harm with whatever consideration makes sense. But the issue at hand is that medically unnecessary surgery is objectively identifiable as harm. There is cutting. There is an inherent risk of complications, both minor and severe. And infants do not have their choice. Objective harm is forced on them without their consent with no medical need or objective benefit.

Statistics demonstrate that, when left with their choice, males almost never choose or need circumcision. Any reasonable person standard must side with not removing healthy body parts from children. They have the same individual rights that every adult has to the extent that a right is inherent and inalienable. For minors, those rights should be viewed as held in trust rather than created upon reaching the age of majority. Since the first legitimate purpose of government is to protect the rights of each citizen against infringement by other citizens, there is no reason to overlook that just because the person imposing the harm is a parent who views the imposition as beneficial in some (subjective) manner.

Again, I don't think Mark's comment indicates that he's willing to overlook anything. He's not rejecting a law. But as he points out there is a societal norm in the United States that male circumcision is just an inconsequential snip. As I've demonstrated throughout my circumcision category, it's not true that it's inconsequential. Even though most American men are content to be circumcised, we are a nation of individuals before any other examination. Adding a new law to include boys protects them as individuals in the same we already protect girls. It is a law that actively advances individual liberty, while actively rejecting an incoherent narrative of liberty dressed in parental "rights".

We shouldn't need a law to protect against infant circumcision. But in a perfect world, parents wouldn't remove healthy body parts from their children out of fear, superstition and conformity. We must legislate for the world we have, with the foundation of individual rights that we know is valid. I could make an argument that existing assault laws cover unnecessary infant circumcision, but no prosecutor is going to pursue that in the common circumstances of male infant circumcision in America. So, barring a sudden shift to rational action by parents, this is an area where the government must legitimately exercise its authority in defense of rights.

Post Script: There's a little more to Mark's comment than what I posted here. I left an additional response there, but it was more anecdotal.

April 06, 2008

How far do parental "rights" extend? What is the basis for limitation?

Passed to me by a friend, let's draw the natural comparison on this story:

Thailand's Health Ministry ordered hospitals and medical clinics to temporarily stop performing castrations for non-medical reasons, saying Wednesday that the procedure performed on transsexuals needs stricter monitoring.
...

"As of today, doctors can perform the surgery if there is a medical reason to do so — not for any other reason," ministry spokesman Suphan Srithamma said.

The move came after a leading gay activist, Natee Teerarojjanapongs, called on the Medical Council to take action against clinics that perform castrations on underage boys.

I don't have any knowledge of this topic beyond what this story offers. I assume it's true that some number of males undergo castration to achieve "feminine qualities". Like medically unnecessary circumcision, neither parental proxy nor choice by a legally incompetent individual should factor. Unlike medically unnecessary circumcision, this appears to be at the male's request. But this is important to remember:

"It's a totally wrong perception that castration will make boys more feminine," Natee told The Bangkok Post last week. "These youngsters should wait until they are mature enough to thoroughly consider the pros and cons of such an operation."

Unfortunately the real problem appears to be doctors overlooking the existing rule requiring parental consent for boys until they reach age 18. I don't think there's contention that enforcing this is reasonable.

So, instead, a thought experiment. I would like to assume that parents are rational enough not to sign off on this type of stupidity. I don't assume that, of course, because the evidence proving otherwise is too strong. But apart from the distinction¹ on future reproductive capability from the two procedures, how is it any more reasonable to permit parents to impose circumcision than to permit them to impose castration? We can discuss degrees of violation, but that's a distraction from the truth that they're the same kind of violation. We don't debate the depth to which it's acceptable to stick a knife into someone, even though differences exist in probable outcome from the depth of the assault.

When considering surgery on minors, any intellectual journey towards acceptance after establishing medically unnecessary is unethical and illegitimate. There is no objective justification, so any legal permission granted to parents by society is subjective reasoning devoid of reason. It doesn't matter if the topic is castration, genital cutting, breast augmentation or any other unnecessary intervention a second-party prefers. The individual isn't just supreme, he is all that matters.

¹ Reproduction is not necessary for the individual to live, so its foundation is subjective, exactly like medically unnecessary circumcision.

April 05, 2008

Overheard on the Internet

Anyone who follows discussion of circumcision on the Internet will encounter regular moments of an overwhelming desire to hate mankind. It's impossible to avoid. People are so devoid of any logic or consideration for the child that disgust is the kindest emotion I can achieve. For example:

But I was also thinking, for all you mummies to be out there, are you thinking of getting your son circumcised? And for those of you with girls or who don't know what you're having, would you get your baby circumcised ? Does anybody know the pros and cons in doing so ?

If you've paid attention to my Circumcision category, you know that actual discussion of pros [sic?] and cons will likely not follow, which is how it plays out. Like here:

It's completely a personal decision ... You cannot make your decision based off of anyone elses opinion. ...

I am here in the US and it is a very common practice. It wasn't even a question for us. Here it is done one day after birth. Neither one of my boys even flinched when it was done. The PlastiBel that they use here takes all of 2 seconds to perform and it's done.

You should really research it so that that you and OH feel that you have made the decision that best suits your beliefs. Good Luck!

Notice¹ that this response ignores the original question. Instead, it's a typical defense of parents making a "personal decision" not based on any other person's opinion, with any other person being inclusive of the healthy child. Whatever suits them is somehow acceptable.

But it gets more blatant:

...

I am not the sort of person to push my views on anyone else but that is what we would do.

Hope you make a decision that you and babies (sic) daddy are happy with.

...

She is mistaken; she is exactly the type of person to push her views on someone else. Her husband is that type of person, too. Neither of them considered that their son might not want to be circumcised. They imagine that only their opinion about his body mattered.

Some inject a little sanity into the discussion, saying it should be illegal. But then comes the inevitable softening to saying it should be a personal decision for the parents based on good reasons. Why? Has one parent on this board who chose to circumcise given any indication that common sense intervened? It should be illegal. That is the only reasonable stance based on more than one analytical approach. Why step away from that? To avoid offending? The legally-permitted violation will continue for some time. There is no reason to enable it longer. Don't be afraid to call people out on their selfish delusions².

<sarcasm> With all of these arguments for and against the procedure </sarcasm>, I can't say I'm surprised by the original commenter's decision:

yeah I think I'm going to get my boy circumcised, seeing as it protects him from all sorts of infections and sexually transmitted diseases, but I heard a story about a man who lived here in winnipeg
He got circumcised when he was a baby and they 'accidentally' cut his penis off! Can you believe it ?

It protects him from UTIs in the first year of life, but the risk is minute without circumcision. (Girls suffer more than intact boys.) And the data on STDs is equivocal, at best. (Condoms? Bueller? Bueller?)

The man she speaks of is David Reimer. His circumcision was attempted using cauterization, which is not an accepted method. While he is important to remember because he was a victim of a botched, unnecessary circumcision, there is (unfortunately) at least one recent example from Canada. The child died.

To the first response I quoted above, the circumcising doctor used a PlastiBell ring on the child.

¹ Notice also that the (unverifiable) claim that it didn't hurt the child is irrelevant. The ability to make a surgical intervention pain-free could justify any number of barbaric procedures. Need matters first, which didn't exist here. Then, when need exists, a scientific conclusion that the most extreme intervention that is circumcision is warranted because no lesser interventions will correct the malady.

Also, did the child suffer any during the healing period?

² From one mother's rambling comment excusing her selfishness:

I am happy with my decision, and I am sure my sons will never come to me saying they wish they still had their foreskin.

I've heard this so many times. No parent ever thinks it will happen to them. I know she's psychic enough to know what her son will want, but what if he asks? And what if he asks because he's not happy about it? Or is he not allowed an independent thought?

April 02, 2008

Delicate Decision: Post 4 of 4

On Monday the Los Angeles Times offered a typical analysis of infant male circumcision. There are many points to address from this story, so I've broken them up into multiple posts. (Posts 1, 2, and 3.)

Point four:

FOR nearly all of Nada Mouallem's pregnancy, she and her husband, Tony, had a running argument. She wanted to have their son circumcised. He didn't. "Many days, I'd go off and research all the pros. He'd go and research all the cons. Then we'd get together at night and fight," she says.
...

For the Mouallems, family tradition and religion were not factors. "We kept those separate and focused only on the scientific reasons," says Tony Mouallem, who was against circumcising his son because he didn't think it was necessary. Plus, he's not circumcised. "You have to work a little harder to keep it clean, but that's not a big deal."

His wife, Nada, however, worried about the responsibility of keeping her newborn's penis clean. She thought circumcision would help reduce the risk of infection and disease. "I wasn't keen on my baby having a surgical procedure, but then I thought, why not if we can offer him more protection?"

In the end, Tony sided with his wife. Their son was born Feb. 10, and was circumcised the next day. Tony held him during the procedure. "There was no bleeding and he didn't even cry," he says. "I'm still not convinced it was medically necessary, but I didn't want to burden my wife with the worry of cleaning it. And maybe it will be easier for him in the locker room."

Choosing surgery over responsibility is the abdication of an obligation when having children. No one states that an intact penis can't be kept clean. Even ignoring the absurdity that it's more difficult to clean in his early years when his foreskin adheres to his glans and shouldn't be retracted, keeping your children clean and eventually teaching them to care for themselves is parenting. Anything else is the selfish subjugation of the child's needs to the parents' whims. In this case, that whim is further discredited because the father presumably understands how to keep an intact penis clean.

Post Script: This most fits the "typical" analysis. These "balanced" articles always contain a couple who can't decide. And the couple always chooses "yes".

More analysis of this article and the CDC's obtuse approach can be found here and here at Male Circumcision and HIV.

Delicate Decision: Post 3 of 4

On Monday the Los Angeles Times offered a typical analysis of infant male circumcision. There are many points to address from this story, so I've broken them up into multiple posts. (Posts 1, 2, and 4.)

Point three:

Robert and Cara Moffat of Los Angeles, who are expecting their first child, a boy, in May, had no trouble deciding, and plan to have their son circumcised. Robert, who is 30 and circumcised, said, "I grew up with it, and my wife has a preference for it, so that's what we'll do. We're doing what the family is comfortable doing."

His father is happy being circumcised, so the boy will be happy with it. This is an unverifiable assumption at birth. His mother prefers having sex with circumcised partners. This is irrelevant because I presume she does not intend to have sex with her son. So it leaves the conclusion that his future sex partner(s), who they apparently know will be female, will prefer that he be circumcised. This is an unverifiable assumption at birth. Finally, "what the family is comfortable doing" is hardly a principle of ethics, liberty, or science.

Also note that the parents have said nothing about (potential) medical benefits in forcing this on their son. Yet, they're allegedly qualified to decide that their son will want this. And legally we're all supposed to think this is reasonable.

As parents and task forces sort through the variables surrounding this intimate decision, [Dr. Andrew] Freedman offers parents in turmoil this comforting advice: "Rest assured. No matter what decision parents make for their son, most men think whatever they have is just fine."

There are four potential realities for an adult male when he is finally legally protected to make his own genital decisions the way females are protected from birth. He can be intact and happy. He can be circumcised and happy. He can be intact and unhappy. He can be circumcised and unhappy. In the first scenario, he could do something but he wouldn't. In the second, he can't do anything but he doesn't care. In the third, he can do something and he will choose either the perceived benefits of circumcision he seeks or not facing the drawbacks from adult circumcision. In the fourth, he can do nothing and society rejects his opinion as an individual.

In the first two scenarios, we conclude that the child validates the parents' decision. We mistake an unrelated outcome for causation. In the third scenario, whatever we conclude, we've achieved the minimum standard of liberty that the male retains his right to choose (or reject) medically unnecessary procedures. In the fourth scenario, we either deny its validity or babble on about the rights of the parents. This generally involves some hand-wringing about parents making lots of tough choices while actively missing that none of the other choices involve removing parts of his anatomy. (You didn't forget that parental rights are greater when speaking of sons, did you?)

Dr. Freedman's opinion tells every man in scenario four his parents' opinions about his penis matter more than his own. Anyone who argues this refuses to reconcile the complete lack of medical need with any notion of ethics and individual rights. Just because science can (allegedly and potentially) achieve an outcome does not mean it should try to achieve that outcome. That is a slippery slope unbounded by any consistent rule or principle.

More analysis of this article and the CDC's obtuse approach can be found here and here at Male Circumcision and HIV.

Delicate Decision: Post 2 of 4

On Monday the Los Angeles Times offered a typical analysis of infant male circumcision. There are many points to address from this story, so I've broken them up into multiple posts. (Posts 1, 3, and 4.)

Point two:

In the first year of life, 1 in 100 uncircumcised [sic] boys will develop a urinary tract infection. Only 1 in 1,000 circumcised boys will. "While that's a tenfold reduction, you have to keep in mind that the risk was only 1% to begin with," says Dr. Andrew Freedman, pediatric urologist at Cedars-Sinai Medical Center. Proper hygiene can prevent most infections.

When considering potential benefits, context matters more than an isolated statistic. For example:

The downside of letting the child make the decision later is that adult circumcision is more expensive, painful and extensive. During an infant circumcision, practitioners numb the site with local anesthesia, then attach a bell-shaped clamp to the foreskin and excise the skin over the clamp. The clamp helps prevent bleeding. In adults, the procedure involves two incisions, above and below the glans (tip of the penis), stitches and a longer recovery. The cost is about 10 times that of a newborn procedure.

Let's ignore the rights of the individual for the moment. I don't, but the hypothetical does, so I'll stick with it. The cost is about 10 times that of a newborn procedure. So what? As a fact on its own, it means nothing. How likely is it that an intact male will need circumcision in his lifetime? If it's less than 10%, and it is, then a basic cost-benefit analysis shows that we will spend less overall by circumcising only those males who medically require circumcision. The "ten times more expensive" meme is worthless upon minimal inspection.

Dr. Freedman seems to understand this:

"The HIV data is the most compelling to date that circumcision can help prevent the transmission of the virus in male-female sex," Freedman says. "While this is important to sub-Saharan Africa, the question is how many infant boys need to be circumcised in the United States to prevent one case of HIV transmission 25 years from now? Factoring in even the rare complication that can occur with circumcision may render this study insignificant."

No kidding. Aside from not being able to predict who (or if) circumcision will help prevent HIV, we can also not predict who will suffer a complication. I seriously doubt the few children who suffer a significant mutilation of the penis care that most circumcisions are "successful". Nor do I suspect the few boys who die from circumcision care about the general outcome. Of course, this should matter now, even before reducing a child to his (unknown) place in the statistical herd.

But he might not get it:

If parents do opt for the procedure, Freedman advises that they do it when the baby is a newborn, have someone trained and experienced perform the procedure, and use pain control. "The older a child gets, the less benefit there is, and the greater the risk," he says. "I would ask parents of an older child to strongly reconsider if the only reason they're doing this is cosmetic."

The parents of a newborn who choose circumcision for cosmetic reasons? Those are somehow okay? Again, the individual - the patient - matters. When he is healthy, every other outside opinion is meaningless to the consideration of his body.

More analysis of this article and the CDC's obtuse approach can be found here and here at Male Circumcision and HIV.

Delicate Decision: Post 1 of 4

On Monday the Los Angeles Times offered a typical analysis of infant male circumcision. There are many points to address from this story, so I've broken them up into multiple posts. (Posts 2, 3, and 4.)

Point one:

Dr. Peter Kilmarx, chief of epidemiology in the CDC's division of HIV/AIDS prevention, says the CDC is looking at how the findings apply here. "The early opinion from the consultants -- and not the position of the CDC, which involves a peer review process and public comment -- is that, given all the previous data on circumcision plus the recent HIV African studies, the medical benefits of male infant circumcision outweigh the risks and that any financial burden barring parents from making this decision should be lifted," he said.

Nationalizing health care will no more end routine infant male circumcision in America than the elimination of Medicaid funding has ended it in the states where Medicaid no longer pays for the unnecessary procedure. There is a political constituency that strongly supports imposing this on children. Until the universal principle that each individual owns his or her body is codified into law for males the way the Female Genital Mutilation Act now protects female minors, medically unnecessary circumcision will continue. And the state will pay for it when parents can't (or won't). Any protection of the individual based on entrenching an existing, or establishing a new, collective will fail.

Here's a half-point in which I doubt Kilmarx understands the missing half:

"The procedure is so ancient, and steeped in cultures, I'm not surprised that the rate of adult circumcision in civilized countries doesn't track with medical evidence," Kilmarx says. "But as scientists, we don't solely rely on what other countries do as a guideline."

But as Americans, we don't (mustn't) solely rely on what science tells us as a guideline. Ethics matters. The rights of the individual matter, particularly the healthy individual. There is a hierarchy for decision-making concerning surgery on children. Kilmarx, among many, does not start at the beginning (i.e. medical need). That leads to mistakes, as clearly shown by the million-plus unnecessary infant circumcisions performed every year in America.

More analysis of this article and the CDC's obtuse approach can be found here and here at Circumcision and HIV.

March 25, 2008

Science requires evidence that faith can't provide.

This British article on circumcision demonstrates several typical lapses in critical thinking. These lapses are usually based in a refusal to consider that actions against children are subject to ethical concerns. That fits these examples. First:

One part of the country that is moving quickly in this direction is Walsall, where the local hospital now offers a weekend male-circumcision clinic. “We have a large Muslim community here,” says Dr Sam Ramaiah, director of public health for Walsall Primary Care Trust, “and we wanted to provide local children with a service that is safe and secure. The procedure takes place in hospital with local anaesthetic and is done by a trained surgeon. The advantage is that there is care available in case of complications and, if necessary, the child can stay in.

The possibility of complications demands that circumcision be medically indicated based on need when the patient can't consent. It may be more civilized to offer this service so that children may have their genitals cut in a "safe" environment, but it is not civilized. And it's not equal; the same concession is not made to parents for cutting the genitals of their female children. Ethics - morality - requires more than good intentions and a clean operating room.

Next:

If there was any hint that there was a physical or psychological problem it would have been suspended centuries ago, something that has happened to other practices in Judaism. And indeed things have changed already. Nowadays we will use only mohelim [people who perform ritual Jewish circumcision] who are doctors. We always use anaesthetic cream. If there is anything that indicates that we should delay the circumcision we will delay it,” [Rabbi Jonathan Romain] says.

The ethical demand from a lack of medical necessity indicates that we should delay the circumcision, so clearly Rabbi Romain is mistaken. But he mistakenly does not accept that fact, so I'll move to his specific point.

"We're modern, so we would not continue doing something harmful. We are incapable of it because we are modern. Someone, somewhere, would've stopped this if it was bad." This idea is a typical fallacy that relies on an arrogance founded in the rejection of self-examination. It rejects the science of medicine as an ongoing quest, preferring instead an unstated belief that we know all we may know. Unfortunately, it also relies on knowing only what we want to know.

How long did medical science accept blood-letting as a cure? Have we mostly abandoned the practice now in favor of new understanding? Should men and women of science ceased progress by assuming that progress had reached its pinnacle?

Being a doctor requires ethics, but even in the absence of ethics, science provides the answers to the objective questions. Removing the foreskin is an objective change in the genitals. Cutting is objective harm. (Rabbi Romain proves this, since anesthetic cream would be unnecessary if cutting wasn't objective harm.) When there is no medical indication for doing cutting, all that remains is the subjective evaluation of the benefits versus the costs of genital cutting. The doctor (and parents) are not qualified under any circumstance to conclude in favor of cutting when the child's genitals are healthy. All arguments regarding benefits are irrelevant.

March 21, 2008

Our gender discrimination permits this immoral argument.

Following on previous entries regarding female genital mutilation, John Tierney updates the conversation with an opinion from Dr. Fuambai Ahmadu, "a native of Sierra Leone, who grew up in America and then went back to her homeland as an adult to undergo the rite along with fellow members of the Kono ethnic group." I'm not impressed with Dr. Ahmadu's reasoning.

I also take note of readers’ concerns about consent. While I have serious issues with the concept of consent and how it is applied asymmetrically to African practices of female genital cutting, I do agree with Rick Shweder that a possible way forward would be to consider limiting certain types of genital cutting to an age of majority, for instance, the age at which a girl can consent to marriage, abortion or to cosmetic surgery. A minor procedure can be allowed for girls under the age of consent, as is the case with infant male circumcision. Defining what such a minor procedure would entail and what might be the appropriate ages of consent is an important step that must include the voices of the “silent majority” of women who are affected.
...

The way forward is to look for solutions that would empower women (and men) to choose what to do with their own bodies. ...

My position is “pro-choice” on any form of female and male genital modifications (with the exception of minor cuts, such as circumcisions of male and female prepuce discussed above) and a complete rejection of the motto “zero-tolerance of FGM”. ...

That's an interesting notion of choice. Dr. Ahmadu conflates the prerogative of a cultural group¹ to exclude those who do not conform to its rituals with permission to require inclusion through involuntary participation among those who reject its rituals. This ignores the real issue, the use of force on a healthy, non-consenting individual.

Pro-choice should mean what it implies, which is complete consent or refusal. There are no other valid competing interests on the individual when critiquing elective genital surgery. If the person agrees, for whatever reason, it is his or her choice. If the person does not agree, for whatever reason, it is forced. If the person cannot consent, for whatever reason, the assumption must be that he or she would not. Force violates his or her rights as an individual to self-ownership. Permitting force relegates the body part(s) under consideration to property status, possessed without limitation by another. That can never be right.

Introducing subjective qualifications (i.e. minor cuts) is then a diversionary tactic based on a relativist notion of what people should not mind based on the good opinion of others. It is not a principle that recognizes the individual. It rejects a coherent conception of human rights.

Dr. Ahmadu's minor is my major. Her blessing of my forced circumcision as a cultural rite is irrelevant to the point of offensiveness. I believe in choice. She believes in choice, unless force is necessary to achieve her outcome.

Post Script: Dr. Shweder contributed a comment to the discussion suggesting a curious denial of some of the earlier counterpoints made throughout the threads. I offered a new rebuttal here.

¹ Do not read this as a synonym for government. No government has such authority, nor do citizens possess a right to use government to exclude citizens from society.

March 16, 2008

Can we frame the debate objectively?

In response to this Will Wilkinson entry and this Kerry Howley entry on the liberty arguments for (economics) and against (morality) legalized prostitution, Ross Douthat goes off the rails with a strange question of how prostitution as sex work differs from molestation and incest. It's as ridiculous as it sounds. Read Mr. Wilkinson's response, with all the obvious goodness such a question demands.

Instead, I want to focus on this one sentence from Mr. Douthat's entry:

If you think that sex, by virtue of being bound up not only culturally but biologically with emotional attachment on the one hand and reproduction on the other, is a unique kind of physical act, one that’s intimate by its very nature in a way that, say, preparing dinner isn’t, then it makes sense to assign a hierarchy of moral value (and moral stigma) to different kinds of sexual activity – most likely with monogamy at the top, serial monogamy somewhat lower, promiscuity lower still, and activities that treat sex as a commodity to be bought and sold somewhere near the bottom.

Of course it makes sense to assign that hierarchy if that's what you think. But not everyone thinks that. Perpetuating individual liberty demands more than caving to a squishy notion of universal disdain for an activity. Even, and perhaps especially, when one finds activities at the bottom of that hierarchy morally repugnant.

The validity of arguing for the legalization of prostitution does not hinge on the moral argument with regard to selling sex. It is acceptable to believe that an activity is morally unacceptable, yet to acknowledge that two consenting adults may engage in that activity because they are not harming others. Or more precisely, if they are harming anyone, it is only themselves, voluntarily. That question of liberty is at the core of this debate, not the moral defensibility of prostitution.

Free to engage and should engage are different concepts. Ms. Howley and Mr. Wilkinson argue only the former. This (implicitly) injects into the debate the truth that all tastes and preferences are subjective. It sets such subjectivity aside and leaves the legal question only to evidence of objective harm.

For fairness, Mr. Douthat posits in an earlier entry that sex work is by definition self-abuse, justifying a legal prohibition. The posts he responds to in the above links address that argument.

**********

Of course, since it's apparently okay to ask questions unrelated to the topic, let me ask a question: Why is it automatically self-harm worthy of prohibition for an individual to sell sex, even when it's voluntarily sold, yet it's reasonable to permit parents to surgically alter the genitals of their healthy sons - who may or may not approve of such permanent, physical alteration - as Mr. Douthat suggested last year in defense of infant circumcision?

The answer to how one person can hold two incongruent opinions rather obviously rests in a willingness to use personal, subjective tastes and preferences to inform the legal code of a diverse, secular, civil society. It's the same central planner impulse that resides in every individual who seeks to dictate which freedoms are abhorrent.

Since I'm off on the tangent, in that entry, Mr. Douthat states:

Proponents, like myself, point out that even saying the word smegma is really disgusting. Again, I think we pretty much win the debate right there, without even getting into the whole HIV question.

I get the tongue-in-cheek nature of the comment, whether he meant it or not. I think he did because I think he views circumcision as inconsequential. (Remember subjective tastes and preferences?) But any understanding of human biology demonstrates the stupidity of such an argument. Female genitals produce smegma, as well. We do not cut female minors for that reason. Or, more to the point, we do not permit parents to cut their daughters just because they, the parents, are disgusted by the mere mention of the word. We manage to find the correct reasoning to prohibit that. But for males, parents can use only the mere mention of smegma as an excuse to cut. Or they can reject even that reason and order it because it's fun to check "yes" on the consent form. The law is based on our conditioned beliefs rather than facts.

Just as it is with prostitution.

March 12, 2008

Parents as middle-man is an interesting twist on proxy.

This article demonstrates the view many people have when they make their child's decision to circumcise him (or her) absent any medical need.

According to a press release from the Ministry of Health, the sessions for children who wish to be circumcised will be held during the first-term school break from March 18 to March 30, 2008.
...

Parents or guardians who wish to acquire these services for their children can directly contact...

Parents aren't imposing their preferences, they're merely acting as agents for their children's wishes. That may make people feel better, but it doesn't change the action from wrong to right.

March 11, 2008

Liberty is the center.

In what will probably be my only post on Eliot Spitzer's sex scandal, I'm not going to talk much about his sex scandal. I just don't care about the sleaze. His hypocritical moral thuggery speaks for itself, although I'm perfectly happy to witness every libertarian rip him. I'm just not willing to pretend that this will in any way assist the return of individual liberty to the legislative process surrounding consensual, victim-less transactions of subjectively-questionable morality¹. At best, I'm willing to consider that it might discourage politicians from private misbehavior. Upon reflection, and before completing the previous sentence, I accepted that Spitzer's fall will discourage nothing. The hubris of politicians to preen in public crusades while mucking around in the filth in private is going nowhere. In other words, this is just another sex scandal that will, at most, ruin Spitzer's political career.

Instead, I want to examine Kip's response to Glenn Greenwald's question on the matter. First, Greenwald's question:

[A]re there actually many people left who care if an adult who isn't their spouse hires prostitutes? Are there really people left who think that doing so should be a crime, that adults who hire other consenting adults for sex should be convicted and go to prison?

To which Kip replied:

Actually, the "need" to criminalize prostitution is one of those rare worldviews that unites radical conservatives ("morals," "social fabric," etc.) with radical liberals ("oppression of women," "the powerful exploiting the powerless," etc.).

While the Vast Center-Wing Conspiracy just shrugs it off.

I think that's spot-on. Our society's puritan response to sex is not exclusively a trait of social conservatives. That belief may be more prevalent on the right, and I think it's more explicit there, but it appears in various forms on the left. As Kip highlights, only the reasoning is different. The revulsion is identical.

There's no reason for me to comment on that with an entry of my own rather than a comment on Kip's original entry, so allow me to expand where I think his logic applies. Since I'm writing it, my thought process applies to genital mutilation. There is a comparison to be made in the mistaken logic applied based on gender. As it applies to female genital mutilation, I'd write the comment like this:

Actually, the need to criminalize female genital mutilation is one of those rare worldviews that unites radical conservatives ("anti-Islam," "nationalism," etc.) with radical liberals ("oppression of women," "the patriarchy²," etc.).

While the Vast Center-Wing Conspiracy just understands that the individual's right to be free from unnecessary harm is all that's necessary to denounce and prohibit female genital mutilation.

Although the conclusion is the same, the approach matters. The Vast Center-Wing Conspiracy relies on the principle rather than its own subjective interpretation of what is right and wrong. It leaves open the idea that the individual could choose something different, but leaves open only the idea that the individual should choose.

With male genital mutilation, I'd write the comment like this, with the obvious reversal of the original prostitution argument on criminalization versus legalization:

Actually, the "need" to legalize male genital mutilation is one of those rare worldviews that unites radical conservatives ("parental rights," "conformity," "religion," etc.) with radical liberals ("parental rights," "women's sexual preferences," "women's sexual health," etc.).

While the Vast Center-Wing Conspiracy just understands that the individual's right to be free from unnecessary harm is all that's necessary to denounce and prohibit male genital mutilation.

I am not making the claim to the prevalence of these world views or that they approach a tipping point close to a majority. But I have encountered every one of them in person and on the Internet. And politicians (and courts) accept every one of them.

Still, the central point remains. Those who rely on principles of individual liberty arrive at the same conclusion, which is equal treatment (i.e. protection) for all people, regardless of gender. There is a foundation that isn't open to political whims and/or faulty personal character. This Center-Wing Conspiracy grasps the point of a civil society and acts to make it reality.

Everyone else just pretends that his or her personal, subjective tastes and preferences for a traditional practice should apply to everyone. There is no concern that the other individual might not choose the same³. There is no recognition that, if he or she chooses differently, he or she is not automatically wrong. There need not be any delusion or coercion.

The difference between principle and ideology is important.

¹ Paying for sex? Not immoral. Paying for sex with someone other than one's spouse? Not necessarily immoral. Paying for sex with someone other than one's spouse when that spouse has not/would not agree to such marital terms? Immoral. Each person is entitled to his or her own private shades of gray.

² As if males can't be the victim of the patriarchy. As if women can't be the instigator in "the patriarchy". (Any look at the scope of FGM advocates demonstrates the fallacy in that belief.) The only thing I know for sure is that when I see the patriarchy in a debate, I stop to question the receptivity of all participants to the complete, objective set of facts informing the debate. With the FGM debate, this receptivity is generally very low.

³ A common argument in favor of permitting genital mutilation of male infants is "if you don't like it, don't do it to your kids." These people miss the point because they don't rely on any principle.

March 04, 2008

Root for individual liberty and America will succeed.

I fully expect to vote for myself in November, if I bother to vote at all. But just for fun, I'm researching some of the Libertarian Party candidates. On my first look - in this case, Wayne Allen Root - I'm not so thrilled. Consider some of his positions:

I support the Line Item Veto. I will push relentlessly and tirelessly to make this a crucial part of the President's arsenal to fight the deficit, cut waste, and balance the budget.

Saying how he intends to achieve this is important, since it explains his understanding of the government process. However, he does not say how he intends to do this, so I will not assume his preferred path for achieving this. But I will suggest Article 1, Section 7 of the United States Constitution as a starting point:

Every bill which shall have passed the House of Representatives and the Senate, shall, before it become a law, be presented to the President of the United States; if he approve he shall sign it, but if not he shall return it, with his objections to that House in which it shall have originated, who shall enter the objections at large on their journal, and proceed to reconsider it.

This requires the President to address each bill in its entirety. He may not isolate the pieces he likes from the pieces he detests. The only valid approach to the line item veto is a Constitutional amendment.

My preference on this is simple. The Congress should narrow the focus of bills it presents to the President for approval. A defense bill shouldn't have education issues attached, for example. The President should reject every bill that doesn't meet this test until Congress begins legislating in this manner. This isn't perfect because Congress gets leeway in how narrow it defines a topic, but it is an immediate solution.

Next, Mr. Root offers this:

I support gay rights and civil unions. Gay marriage however is not a federal issue. It is a States' Rights issue only.

This raises two problems. First, the 16th Amendment forbids the states from denying "to any person within its jurisdiction the equal protection of the laws." Marriage, as a civil contract, is an individual right to enter into a voluntary agreement. It is not a group right belonging to two people. Such an idea is absurd, given our understanding of individual liberty, but it also assumes that two people share a right before they meet. Whoever you will marry shares this right with you. That's ridiculous. Defining the individual right to contract down from the right to enter into a contract with another competent, willing individual to a right to enter into a contract with another competent, willing, opposite-sex individual is anti-individual liberty. That incorrectly achieves equal at the expense of liberty.

Second, states rights appears multiple times in Mr. Root's positions. No government has rights. Governments have powers. These powers are granted from the people, not because the government has a legitimate claim to them, but because the people trade some amount of liberty in exchange for specific outcomes. I trade my "right" to harm to protect my right to remain free from harm. Government does not grant rights. It protects inherent rights.

In other words, it is little consolation to be oppressed by my neighbors through my state/local government instead of my countrymen in another state through our federal government. This sort of nonsense appears multiple times in Mr. Root's positions. It's the same fallacy made by Ron Paul in too many of his positions. (Remember, Ron Paul is not a libertarian.)

Here's one last position from Mr. Root:

I support the separation of church and state. However I also believe in tolerance for rights of religious Americans too. I believe in school prayer, God in our pledge of allegiance and on our currency. To remove these religious symbols would be to deny the rights and freedoms of religious Americans. I would also protect the rights of those who do not believe in God or religion to not participate in any public prayer or religious activities.

This is troubling. Removing these religious symbols from the private sphere would be to deny the rights and freedoms of religious Americans. To remove them from the public sphere denies nothing.

School prayer is fine, in a private school. That is not what is up for debate. Arguing otherwise suggests dubious integrity. Mention of God in our pledge of allegiance, as legislated by Congress, is problematic. We do not have a private currency, and the government actively seeks to stamp out such efforts, so "In God We Trust" on U.S. currency is a violation of the First Amendment. While the latter two are minor in scope, if not principle, none of the three are valid in government as public requirements. They have nothing to do with tolerance for individual rights.

I do not wish to suggest that there is a libertarian purity test based on policy recommendations. I don't; I think that fallacy is counter-productive. However, I think there is a valid libertarian purity test on thought process. If Mr. Root argues for legislation to grant the line item veto, he ignores the Constitution's text. Where Mr. Root argues for states' rights, he misses the point of individual liberty and government of, for, and by the people. Where Mr. Root argues to overlook Congressional indifference to the First Amendment in favor of "tolerance", he abandons the reasoning for a Constitution. None of these positions rely on libertarian principles, which is a valid criteria for judging a candidates credentials.

To clarify, the big libertarian test right now seems to be Iraq. Most libertarians agree that our experiment in Iraq is a mistake. It is a preemptive war without justification based in national security. Unlike Afghanistan, a legitimate war of self-defense, Iraq carried no such immediate threats to U.S. security.

I agree with that analysis. I also think there are libertarians who disagree. I don't mean "people who (mistakenly) call themselves libertarians" disagree. For example, Timothy Sandefur supports the war in Iraq on national security grounds. I disagree with his conclusion from the facts, but he is basing his support on his intellectually-considered conclusion within the framework of libertarian principles of self-defense. It's okay to disagree with him. Such debate pushes us to a better conclusion, in general. But it would be idiotic to suggest that he is not a libertarian because of this policy recommendation.

As another example, I'm clearly against any circumcision of a child that isn't based in an immediate medical need. That is a libertarian position focused on the individual's right to keep his foreskin (i.e. his property) and his right to remain free from harm. Freedom of/from religion is also an individual right, with the child having a claim equal to his parents. It is an invalid excuse. There can be no libertarian disagreement on this.

When there is a medical issue, there can be a disagreement on whether that medical issue requires circumcision rather than some less invasive treatment. The answer requires judgment. I would seek out those less invasive treatments for a child before resorting to circumcision. I think ethics demand all parents and medical personnel do the same. But proxy consent in the face of legitimate medical issues for a legally incompetent individual is valid in libertarian principle, even when it leads to child circumcision.

The likelihood of having the perfect candidate without running for office myself is almost non-existent. Ultimately, the best we can hope for is a candidate who process information through the correct filters. It's too much to expect the same conclusion on every issue. It's reasonable to expect the same respect for individual rights.

February 28, 2008

UNAIDS needs to rebuild its ethical framework.

Following on the last entry, UNAIDS issued another press release (pdf):

Two United Nations agencies have issued a joint call to boost protection of the human rights of people regardless of their sexual orientation or their actual or presumed HIV status.

In a statement, the Joint UN Programme on HIV/AIDS (UNAIDS) and the Office of the UN High Commissioner for Human Rights (OHCHR) urged “all governments to be vigilant in respecting and protecting the rights of individuals in this regard, in particular the rights of all to be free from murder, torture, violence, arbitrary arrest and vilification, regardless of their HIV status or sexual orientation.”

The bodies voiced their concern over reports of forced HIV testing, arbitrary detention on the basis of HIV status and the disclosure of one’s HIV status without consent.

Again, this is a noble goal. I agree with it. But UNAIDS fascinates me with where it draws its lines on human rights. Forced HIV testing is bad. Forced genital mutilation¹ is good. Taking a person's blood, which the body will replace, is bad. Taking a male's foreskin, which his body will not replace, is good.

What?

Does this have something to do with intent? Presumably governments are forcing HIV tests on people to facilitate persecution and/or exclusion. That's inarguably bad, since individual liberty based on human rights is a valid principle. Presumably parents are forcing genital mutilation on their male children for its potential to prevent reduce the risk of female-to-male HIV transmission. Even if I assume this intention is Good™, condoms and behavior modification achieve better results. They are the specific, identifiable reasons why we must not abandon the fair and equal protection of human rights, regardless of gender. Yet, UNAIDS rebukes this understanding of rights in favor of fear and panic, with an additional nod to tradition².

Any idea that a right to remain free from unnecessary, unjustified force vests after some extraneous condition is met is invalid. I suspect UNAIDS would argue against that interpretation of its actions. Its actions argue against any other interpretation.

¹ But ONLY on boys; UNAIDS has ethics and how dare anyone who suggests otherwise.

² This argument strikes me as succumbing to fear. It's easier to accept a human rights violation than it is to call it out and risk being criticized by those who practice the tradition. This is the coward's path.

The number of X chromosomes should not matter.

The push for separate rights based on gender has never been so obvious.

Ten U.N. agencies have launched a campaign to significantly reduce female circumcision by 2015 and eradicate the damaging practice within a generation.

In a statement released Wednesday, the agencies said female circumcision violates the rights of women and girls to health, protection and even life since the procedure sometimes results in death.

That is, of course, a noble goal. But how is permitting encouraging male genital cutting any less worthy? (I'll get to "health" in a moment.) Do boys not deserve the same respect? Does every boy facing the circumciser's blade survive his ordeal?

"Today, we must stand and firmly oppose this practice because it clashes with our core universal values and constitutes a challenge to human dignity and health," Deputy Secretary-General Asha-Rose Migiro told the Commission on the Status of Women where the campaign was launched.

"The consequences of genital mutilation are unacceptable anywhere, anytime and by any moral and ethical standard," she said. "Often, female genital mutilation is carried out on minors, violating the rights of a child to free and full consent on matters concerning her body and body functions."

These agencies¹ argue that males don't require human dignity. They argue that males don't require their full, healthy bodies. They argue that moral and ethical standards do not fully apply to males. They ignore that unnecessary genital surgery is carried out on male minors. They reject the notion that a male child has an equal human right to free and full consent on matters concerning his body and body functions.

They defend this idiocy with the following note in the press release (pdf):

In contrast to female genital mutilation, male circumcision has significant health benefits that outweigh the very low risk of complications when performed by adequately-equipped and welltrained providers in hygienic settings Circumcision has been shown to lower men’s risk for HIV acquisition by about 60% (Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007) and is now recognized as an additional intervention to reduce infection in men in settings where there is a high prevalence of HIV (UNAIDS, 2007).

Significant is subjective. The missing word potential before "health benefits" is necessary, since most males have a healthy foreskin with no history of problems when they are circumcised². Very low is subjective. But the key word in that note is outweigh. Who is the appropriate person to evaluate the balance of those two sides? For example, who decides that the inherent risk of death is low enough? These agencies claim that every female must decide for herself from birth, but every male is subject to the decision of his parents until he reaches the age of majority. Females are assumed to be against medically unnecessary cutting until they state otherwise. Males are assumed to be indifferent, at worst, to medically unnecessary cutting until they state otherwise, when it's too late because a portion of their genitals are already gone forever.

The ten agencies involved place political correctness before principle. They possess no moral or ethical credibility.

¹ The agencies are The Joint U.N. Program on HIV/AIDS; the U.N. Development Program; the U.N. Economic Commission for Africa; the U.N. Educational, Scientific and Cultural Organization; the U.N. Population Fund; the Office of the High Commissioner on Human Rights; the U.N. refugee agency, UNHCR; the U.N. children's agency, UNICEF; the U.N. Development Fund for Women and the World Health Organization.

² This omission is damning to the intellectual integrity of the agencies.

February 25, 2008

The issue is always individual rights.

Three circumcision topics, in order from past to present.

First, author Susie Bright wrote the following based on a discussion in her podcast from 2005:

The problem is, it's one thing to decide for the newborn... and it's another to deal with the adult men around you who already had the choice made for them a long time ago. So often people think they're talking about "babies," when they're really talking about themselves.

I'm not deluded into thinking the foundational basis for my advocating against circumcision isn't my complete dissatisfaction with being circumcised. I hate it. I have been and always will be upfront about that. But, that's not where my thinking is on why infant circumcision as practiced in the United States is wrong. What is broken can't be fixed; I'm not trying to fix it. Nor do I need to resolve any phantom psychological problems some imagine I suffer. I'm only making the basic human rights (and common sense) argument I wish someone had made before I was born.

In other words, it's only about me when someone else makes it about me. That involves assuming something I haven't said, or ignoring what I have said. You like being circumcised? Good for you. I'm not trying to convince you otherwise. You think your preference permits you to impose it permanently on a healthy child? Only there do we have a problem.

Next, from a blogger who self-identifies as a (paleoconservative) libertarian, this argument pointing to Time's ranking of voluntary, adult circumcision as a way to reduce the risk of female-to-male HIV infection:

So much for Penn & Teller’s anti-circumcision show [sic]

I've seen the Penn & Teller: Bullshit! episode on circumcision, which its producers describe thusly:

In episode 301, the third season premiere, the mischievous magicians examine the historical, religious, medical and ethical arguments associated with circumcision.

How many of those has the blogger, Josh, ignored? There's the obvious medical argument against circumcising healthy infants, that we don't routinely perform surgery on healthy children that corrects no malady. However, I'm only interested in challenging the direct flaw in pretending that X scientific assertion (reduced female-to-male HIV risk) demands Y response (circumcising healthy infants). X doesn't demand Y. Aside from the easy medical dismissal, the beginning of the ethical analysis informs us that the HIV angle on voluntary, adult male circumcision suggests nothing about forcing infant circumcision on healthy infants, the topic of the circumcision episode of Penn & Teller: Bullshit!.

Finally, for parents who claim a First Amendment right to circumcise their children, consider:

Forty-four percent of Americans have either switched their religious affiliation since childhood or dropped out of any formal religious group, according to the largest recent survey on American religious identification.

The obvious shortcoming is that it's a survey with insufficient detail. It can't specifically rebut any rights claim.

Yet, it demonstrates the valid individual rights counter-argument to the invalid group rights claim such parents make. Freedom of religion is an individual right. Parents have only the individual right to practice their own religion. They may raise their children in that religion, but that is a concession to practicality and reason, not a separate guaranteed right. There must be limits that protect the child's individual rights. That includes his individual right to be free from religion by rejecting his parents' religion. Modifying his body permanently revokes his right. That can never be legitimate.

February 23, 2008

The central planner's impulse is the parental decision-making crutch.

Most of this article from a Portland, Maine television station is boilerplate stupidity. The parents' opinion matters exclusively. It's no big deal. The potential for benefits overcomes the absence of medical need. Every one of those incorrect excuses is the brain output of a narcissist. But this is a different, less-common expression of that:

In the past, pain relief was not commonly used on babies during the procedure. [Obstetrician-Gynecologist] Dr. [Anne] Rainville says she always uses a local anesthetic.

"When I do a circumcision on a baby, they cry less than the baby next door who is getting their blood drawn. The way we do it is very humane and it is not a terrible barbaric procedure as some people might be led to believe," she said.

The use of pain relief is not the primary determinant for whether or not a surgical procedure is humane. Humane intervention requires science. Humane intervention requires medical need. Humane intervention respects individual human rights. Medically unnecessary genital cutting forced on an individual fails every test of humanity.

A doctor can cut off a child's healthy arm without forcing the child to feel it. Only a fool would argue that such a procedure is humane and not terrible or barbaric. Cultural blindness based on tradition and peer pressure does not excuse violating a healthy individuals bodily integrity.

From the Female Genital Mutilation Act of 1995, the discriminatory federal prohibition on medically unnecessary genital surgery on female minors:

In applying subsection (b)(1), no account shall be taken of the effect on the person on whom the operation is to be performed of any belief on the part of that or any other person that the operation is required as a matter of custom or ritual.

Any other person includes parents. And doctors. And God. And Jimmy next door who will (allegedly) tease Billy in the middle school locker room if Billy's parents leave his healthy, normal foreskin intact.

Subsection (b)(1) states:

(b) A surgical operation is not a violation of this section if the operation is --

"(1) necessary to the health of the person on whom it is performed, and is performed by a person licensed in the place of its performance as a medical practitioners; ...

That is humane. Where that exact interpretation is not also applied to males, any pretense that the use of pain relief makes the surgery acceptable is willful denial. It is a shameful ignorance of humanity. It is the permanent subjugation of a part of an individual to another's control.

Post Script: Note Dr. Rainville's statement that boys under local anesthetic cry less. She did not say they don't cry.

February 21, 2008

Two Voluntary Participants

On an interesting concept among plastic surgeons:

"No, Judith. Just … no.”

Lee A. Gibstein, M.D., a plastic surgeon with offices in New York City and Miami, crumpled up the photo of the shiny, preternaturally line-free celebrity I’d brought with me and tossed it over his shoulder. “Oh, c’mon. Why not?” I whined.

“Because you’re a walking advertisement for me, and I don’t want my patients looking as if they belong in Madame Tussauds,” Dr. Gibstein said, setting down his syringe.

Doctors can reject a patient's request for cosmetic surgery? Who knew? (Me.) If only other doctors might consider other examples of cosmetic surgery that demand a "no" in 100% of cases. And wouldn't it be nice if they rejected such requests for ethical concerns rather than (the appropriate for the linked example) marketing concerns?

Link via Kevin, M.D.

February 19, 2008

Denial versus Rejecting Sociological Science Experimentation

Filling in for Andrew Sullivan, Jim Manzi writes about conservatives and science:

The debate about evolution is a great example of the kind of sucker play that often ensnares conservatives. Frequently, conservatives are confronted with the assertion that scientific finding X implies political or moral conclusion Y with which they vehemently disagree. Obvious examples include (X = the Modern Synthesis of Evolutionary biology, Y = atheism) and (X = increasing concentrations of atmospheric CO2 will lead to some increase in global temperatures, Y = we must implement a global regulatory and tax system to radically reduce carbon emissions). Those conservatives with access to the biggest megaphones have recently developed the habit of responding to this by challenging the scientific finding X. The same sorry spectacle of cranks, gibberish and the resulting alienation of scientists and those who respect the practical benefits of science (i.e., pretty much the whole population of the modern world) then ensues.

In general, it would be far wiser to challenge the assertion that X implies Y. Scientific findings almost never entail specific moral or political conclusions because the scope of application of science is rarely sufficient. In fact, for the two examples that I provided, I have tried to show in detail that X does not come close to implying Y.

This maps to the circumcision debate perfectly. Too many advocates against medically unnecessary, routine circumcision of male children make the exact same fallacy. Many Americans, with the unquestioning aide of nearly every mass media outlet, has already made the connection: X = voluntary, adult circumcision reduces the risk of HIV infection, Y = we must circumcise all males, adult and child, willingly or unwillingly. We're losing intellectual ground that need not be ceded.

Regardless of what advocates for the rights of children as individual human being state, the battle for X in the example above is already lost. It will be lost for a generation or more. That does not mean X is true. But to pretend that we're going to win through mere denial is counter-productive. It's possible to qualify any such recitation of X with a challenge to possible methodological flaws, for example. That should be done. It's just not going to change the public perception that X is true.

The key, as Mr. Manzi demonstrates, is that any validity in X does not require Y. This is our strength. Logic demands that we leave healthy children intact. Individual rights demands that we leave healthy children intact. Medical ethics demands that we leave healthy children intact. Easy access to condoms demands that we leave healthy children intact. Until the child can consent or needs medical care, his (and her) healthy body is the only proof we need that proxy consent must be limited.

The facts are what they are. We cannot change that, to the extent that the findings are valid. Although it's useful to remind anyone who misinterprets the scope of those findings that all benefits from genital surgery on healthy children are merely potential, with a very low likelihood of ever being necessary, we do not need to change that. Every study surrounding HIV and male circumcision already involves the two key components we need to demonstrate our case: voluntary and adult. Going beyond those two words requires our reason and intellect to figure out the appropriate application of those facts. We must demand that society use them.

February 13, 2008

Around the Web: Vigorous Nodding Edition

John Cole assesses the Senate's asinine behavior in passing the anti-liberty FISA bill with telecom immunity and pursuing the NFL over Spygate perfectly:

There is a very real and perverse possibility that the NFL will face tougher sanctions for spying on practice squads and covering it up than the telecoms and this President will face for spying on the citizenry and lying about it.

That the Democrats caved so easily on the former is another reason to ignore them as a party of leadership.

Next, Jacob Sullum dissects the problem with too many science journalists and editors:

Any journalist who doesn't feel comfortable going beyond what appears in a medical journal to put a study's findings in context and offer caveats where appropriate has no business writing about science. Reporters can't be experts on everything, but they can ask smart questions and seek informed comments regarding a study's potential weaknesses. If news organizations refuse to do so on the grounds that the study was peer reviewed and therefore must be faultless, they might as well just reprint researchers' press releases. Which is pretty much what they do, all too often.

This is essentially every bit of "journalism" in America regarding circumcision over the last 125 2½ years. For example.

Finally, Colman McCarthy wrote in yesterday's Washington Post on the current steroids brouhaha in Congress:

This is the second time members of Congress have posed as drug-busters cleaning up the great American pastime. Except that drug use -- whether involving legal or illegal drugs -- already is the American pastime, and it is far bigger than baseball.

I'm hoping that Roger Clemens polls the members of Waxman's committee on their use of performance-enhancing drugs. Start with Viagra. Or Cialis, ready for action "when the moment is right" -- say, a congressman stumbling home after a late-night floor vote on an earmark bill. Clemens might ask the members how many need shots of caffeine drugs to get themselves up and out every morning. He might ask the members how often they reach for another shot of Jack Daniels to enhance their performance while grubbing for bucks from lobbyists at fundraisers. And before leaving Capitol Hill, he should grill the allegedly clean-living baseball reporters on how many of them sit in the press box enhancing their bodies with alcohol, nicotine and caffeine drugs. And a blunt or two when night games go extra innings and deadline nerves need steadying.

My stance remains unchanged. McCarthy's essay holds up a mirror to the hypocrisy of today's moralizers, both inside and outside of government.

February 06, 2008

Is the act the crime?

Is this disgusting act criminal because the man assaulted the children or because he practiced medicine¹ without a license:

A Gaston County man, who is the father of a dozen kids by two different women, is now facing even more child abuse charges in Caldwell County.
...

Marlowe and his two wives lived in Lenoir for several years and during that time Amber says he delivered and then circumcised two of his youngest sons.

Police reports indicate that Marlowe used a utility knife and one of the boys even bled extensively.

I understand what most people will argue is the difference between this story and common American practice. I reject such arguments outright. If you think that an operating room and training would be sufficient to overcome the clear assault, you're ignoring that ritual male genital cutting takes place outside of a sterile surgical environment. You're ignoring that training is required because the act is surgery. You're ignoring that surgery was not indicated in the circumcision of these two boys, just as it isn't in more than one million American male infants circumcised every year. You're also ignoring that female genital cutting could pass the same low test, yet we understand that the location and training is indicative only of the person's sense within the confines of insanity. The physical act is assault.

Anyone outraged by the circumcisions in this story who does not object to circumcision as it is commonly practiced in America is a hypocrite.

¹ To the extent that this is "medicine" in its common form, an objectionable claim.

February 05, 2008

Does religion permit you to increase risk to patients?

From the UK:

Women training in several hospitals in England have raised objections to removing their arm coverings in theatre and to rolling up their sleeves when washing their hands, because it is regarded as immodest in Islam.
...

Dr Mark Enright, professor of microbiology at Imperial College London, said: "To wash your hands properly, and reduce the risks of MRSA and C.difficile, you have to be able to wash the whole area around the wrist.

"I don't think it would be right to make an exemption for people on any grounds. The policy of bare below the elbows has to be applied universally."

U.K. health officials want to apply this universally to all health care practitioners, individuals who enter into voluntary employment contracts. This is, of course, the proper decision because it's based in science and objectively applied. No one has a right to put others at risk to satisfy your religion.

For consideration: how is that view compatible with a belief that parents have the right to impose the risks and negatives of medically unnecessary circumcision on their healthy children, as long as their religion requires it? Is the patient's health and welfare relevant, as it clearly is in the example above?

We are not a civilized society.

From Ask the Rabbi with Rabbi Ritchie Moss:

QUESTION: A friend asked the other day why we have a bris (circumcision). I rambled on about health, tradition, 8 days, pain and a whole lot of other nonsense before leaving this one to you.

ANSWER: The bris is a physical symbol of the relationship between G-d and the Jewish people. It is a constant reminder of what the Jewish mission entails.

I do not care if an adult uses these reasons or no reason to have himself circumcised. I think faith is as valid as any other subjective reason for choosing elective surgery, if that's what the individual values.

Everything that follows in the Rabbi's answer is applied to infants. For that reason alone, all of it is objectionable because they can't express how they'd like to practice their religion (permanently) on their physical bodies. This particular bit is also immoral [italics mine]:

Why on earth would G-d choose circumcision to represent something sacred?

Jewish spirituality is about making the physical world holy. The way we eat, sleep, work and procreate should be imbued with the same holiness as the way we pray our homes should be as sanctified as our synagogues.

We find G-d on earth just as much (and perhaps more) than in the heavens. So we put a sign on the most physical and potentially lowly organ, to say that it can and should be used in a holy way.

In fact, it is in sexuality that we can touch the deepest part of our soul, when we approach it with holiness.

Rabbi Ritchie Moss is possibly expressing his own interpretation. I have no idea how widely this is held. It doesn't matter. When people say that male genital cutting does not occur to affect male sexuality, they are either ignornant or lying.

"Potentially lowly organ". Remember that he is referring to the penis of a male child who is eight days old. (Female sexuality can't be "lowly" and unholy?) The mere presence of his natural penis suggests not only his lack of future sexual purity, but also the punishment for his conviction. That is fucked up. No civilized society would allow that.

Basics do not possess nuance.

This blog entry at Feministe is from last week. It references a strange Erica Jong column that isn't worth discussing. While I agree with most of the Feministe entry, I do not understand how these two ideas can be in the same work. [All emphasis in excerpts is mine.]

I think I’ve made my feelings on male circumcision relatively clear. But you are out of your damn mind if you think that male circumcision is anything like most forms of female circumcision. The majority of female circumcisions involve removing part or all of the clitoris, which is simply not analogous to the removal of foreskin; a more appropriate comparison would be between removing the clitoris and snipping off the head of your dick. Female circumcision isn’t less bad because women don’t think about their vulvas (trust me, we do – and were you to suggest removing a part of mine, I’d be pretty damned opposed to it, despite my interests in children, writing and politics). It’s perfectly possible to question the cultural practice of male circumcision without playing the “what’s-worse” game with female circumcision.

I am out of my damn mind (with the proper nuance), as any regular reader knows, but I'll expand on this in a moment. From further down in the entry:

... For me, it’s a basic bodily autonomy issue: Foreskin may arguably not be a huge deal, but I think it’s simply wrong to remove a part of a person’s genitals without their consent.

In my insanity, I'm still able to see all facets of both male and female genital cutting. I've never argued more than basic bodily autonomy. But if acknowledging that the victim's gender is irrelevant to the fact that a basic violation occurred means I'm out of my damn mind, so be it. I do not want that definition of sanity.

As I've written before, the WHO recognizes 4 types of FGM. Most are physically worse than typical male genital cutting, and those types are far too common among the four. This is a disgrace to mankind, but so is any form of mutilation, even if it results in less damage than the typical male genital cutting. The issue is one of basic bodily autonomy, not severity of damage. In a perfect world where all unnecessary, forced genital cutting is prohibited, it would probably make sense to enact different punishments based on the extent of damage inflicted. But some punishment would be appropriate in every case because each cut is an assault.

In our imperfect world, we outlaw "lesser" cutting on females and congratulate ourselves on our respect for their rights. Many who see male genital cutting as a violation properly suggest that it should be prohibited. But the moment any moral equivalence is made that both victims are human beings with the same inherent rights, the fight is on. Why? It's possible to understand the difference in quantitative damage in most cases while realizing that analyzing that is secondary to recognizing the qualitative violation in every case. Knowing that both are wrong is not an argument that the typical male genital cutting is as damaging as infibulation. In other words, don't read into my words anything other than what I am explicitly saying. Medically unnecessary genital surgery on a non-consenting individual is wrong because it violates basic bodily autonomy. Gender is irrelevant in determining the existence of a violation or the need for prohibition.

Continuing from the last excerpt:

However, I don’t think circumcised men are horribly “mutilated.” I don’t think that there’s anything weird or unattractive about it. I don’t think that they’re all psychologically scarred. And I think it’s shitty to suggest otherwise.

I agree, to an extent. Each individual circumcised male must reach his own judgment about the effect of his circumcision. For me, I consider it a horrible mutilation, it's weird, and it's unattractive. But I don't think this is true for all men, nor do I need to convince any man that he should agree about his own body. Where anti-circumcision advocates attempt that, we are misguided. But those men who believe as I do should not be dismissed. (I do not think the entry "dismisses" me.)

I've seen the psychologically scarred comment a lot. It's generally offered by circumcision advocates who think that "circumcision for(ced on) all males" is a great policy. They can't comprehend that someone would disagree, even though they readily understand that no female would ever want her genitals cut, even when evidence suggests that some women choose it¹. That's just the other side of the incomplete analysis usually offered when comparison between female and male genital cutting appear.

The few comments to the entry that addressed this were less than enthusiastic about calling out this nonsense. For example:

Trixie23 says:

THANK YOU for clarifying that female circumcision is NOTHING to compare to male circumcision…it shouldn’t even be called that. Female circumcision is an AMPUTATION!

It is an amputation, except where it's not. Or where it is an amputation equivalent to male genital cutting.

Also:

# Lizzie (greeneyed fem) says:

Also - I know we’re all on board with the FGM not being anywhere near in the same category as male infant circumcision - but can I just point out that most dudes are circumcised around birth?

I’m not a guy, so I don’t know what kind of affect that has on you - but I remember NOTHING about my hernia surgery from when I was two weeks old. I’m pretty sure I would remember someone taking a knife to my genitals at age 11 or 12, which is when most FGM happens.

The surgery is not wrong because you can remember it. Age of imposition is as irrelevant as gender in understanding that medically unnecessary genital surgery on a non-consenting individual is a violation of basic human rights. Those rights are inherent at birth, not when the child reaches 2 days, 9 days, or 10 years old.

¹ Elective vaginoplasty in America is the easiest comparison, but there are examples in countries where FGM is common. I'll agree that if you want to argue that those women are influenced by cultural pressure, but I'll argue the same holds true for male circumcision in America. People do many stupid things for reasons directly contradicted by evidence proving otherwise.

January 28, 2008

Thanks for contributing.

Jan. 29th Update: I want to clarify that this entry - and DK's at The Kvetcher - is based on an educated guess. I've seen nothing explicitly confirming that PEPFAR (i.e. you and me) will be paying for infant circumcisions in Rwanda. But it defies logic to assume that the United States government will not fund at least a portion of this. We've already funded circumcision in Africa in the past, and the Bush Administration only halted that nonsense temporarily.

Regardless, the statistics on HIV and circumcision in Rwanda stand independent of my guesswork. End Update.

Via The Kvetcher, I'm sure you'll join me in being not surprised to discover who is paying for the new mass circumcision plan in Rwanda that explicitly includes children: you and me, as taxpayers, through PEPFAR.

Additional Funding: In June 2007, an additional $10,600,000 was allocated to further strengthen activities in HIV/TB, PMTCT, Treatment, OVC, SI and Care. The additional funds will also support innovative wrap-around programs targeting PLWHA in the areas of food, micro-economic activities and safe water, as well as new medical male circumcision activities.

Remember how PEPFAR designed its plan to spend money our money?

President Bush's $15 billion anti-AIDS program will begin investing [SIC!] significant money in making circumcision available to African men seeking to protect themselves from HIV, top U.S. health officials said Sunday.

I'm sure I was just being hysterical when I wrote:

The worst part of this is easy to predict. This money will be used to fund infant circumcisions, regardless of what the parties involved are now claiming. That's just the inevitable line of (non-)thinking from public health officials. If it wasn't, we wouldn't have seen the push for infant circumcision six days after the latest findings on voluntary, adult circumcision were released in December. Voluntary and adult always get lost. Always.

Look at the plan in Rwanda. Even where they remembered adult (soldiers and police officers), they dumped voluntary. The desire to "help" here is wrapped in control, fuzzy feelings, and the spread of one specific American custom to future generations. There is no concern for individual rights, the single most important American custom worth spreading.

And about that public health help... From MEASURE DHS, a statistic, which the report¹ provides the conclusion in a neat summary. (Found via the first comment to The Kvetcher's post.)

15.3.6 HIV Prevalence and Male Circumcision

The RDHS-III included questions on whether men had been circumcised. These data can be used to examine possible relationships between HIV prevalence and male circumcision. Among men age 15 to 59 who were tested for HIV, 9 percent had been circumcised.

Table 15.11 indicates higher prevalence of HIV among circumcised males (3.5 percent) than among uncircumcised males (2.1 percent). This pattern is found for all sociodemographic variables, except urban residence, where prevalence among circumcised men (5.0 percent) is slightly lower than among uncircumcised men (5.7 percent).

The facts, although interesting, are clearly irrelevant. When one can appear to act logically, there is no need to worry whether or not that act is logical. Thus always with public policy. Infants be damned.

¹ Institut National de la Statistique du Rwanda (INSR) and ORC Macro. 2006. Rwanda Demographic and Health Survey 2005. Calverton, Maryland, U.S.A.: INSR and ORC Macro.

January 25, 2008

Liberty has age and gender restrictions.

This will probably be long; please humor me. Also, there are many issues of custody that I'm ignoring. I'm specifically focusing on how the Oregon Supreme Court addressed male genital cutting (i.e. circumcision) in its decision. Lest you decide from my last entry that I'm happy with the outcome, I'll spoil the conclusion now and tell you that I am not. The decision is terrible in its dismissal of the clear violation of forced circumcision. I predict that the boy will eventually be circumcised, regardless of his wish. If he says no, the court will decide that the custodial father retains the "right" to impose elective surgery.

With that, the Court's opinion in detail:

We allowed mother's petition for review and on de novo review we now conclude that the trial court erred in failing to determine whether M desired the circumcision as father contended or opposed the circumcision as mother alleged. (1) Because we view that finding as a necessary predicate to determining whether mother alleged a change in circumstance sufficient to trigger a custody hearing, we reverse the decisions of the Court of Appeals and the trial court and remand the case to the trial court.

This seems so fundamental that I question how the Oregon Supreme Court can be blind to the issues surrounding circumcision. Obviously the proposed patient should be consulted. Indeed, barring medical need, his decision is all that matters. As we'll see in a moment, all other considerations are extraneous. (Again, I am ignoring the custodial questions here.)

In the normal course, religious and medical decisions such as the one in this case, are considered private family matters determined by the parents or between parents and child, without resort to the courts. Unfortunately, however, these parties cannot or will not resolve this matter without court intervention.

As I've written before, normal and common have different meanings. They are not synonyms. The Court is correct that we commonly misbehave this way, but that is not normal. Just like having a foreskin is normal, while being circumcised is common.

Oregon does not allow parents the decision to cut the genitals of their daughters for any reason other than medical need. They cannot claim a deity's commandment. They cannot claim a potential benefit. Without medical need, the state applies an absolute prohibition. As our society is built on individual rights, proxy consent must have strict rational bounds. Non-medical elective surgery is outside those bounds. Gender is not a valid basis for distinction.

Father also argued that the court lacked authority to grant mother's motions because (1) granting the motions would violate father's freedom of religion under the religion clauses of the United States and Oregon constitutions; ...

The First Amendment's protection of religious freedom is an individual right. By practicing your religion on the body of another, you have negated his individual right through substitution. That violates the spirit and letter of our Constitution. Any claim to the contrary is a mistaken display of ego.

... (4) the circumcision was medically advisable independent of the religious reasons for it; ...

Doubtful. I'll explain more on this in a moment.

... and (5) although M's wishes were "legally irrelevant," ...

A child does not possess the option to fully exercise his (her) rights while still a minor. That is a reasonable acknowledgement that minors do not possess the mental ability to comprehend their actions. That does not mean they are the property of their parents until reaching the age of majority.

We would not permit parents to surgically amputate a child's finger without medical need. There is no valid distinction that the foreskin from the same protection given to the pinky. Or the labia and clitoris. The father's claim here is absurd bordering on obscene. The Court should've rejected it.

[M's urologist Dr.]Ellen also stated that there was evidence of "glandular adhesions" on M's penis that should have disappeared by age three, and that that fact alone was cause for recommendation for the procedure.

Again, this is normal versus common. It is normal for the foreskin to adhere to the glans at birth. This adhesion commonly breaks by an early age, but it is possible for the adhesions to remain into the teen years. The presence of adhesions does not automatically indicate medical need, just as an absence of adhesions does not automatically indicate medical health.

As the boy ages, the presence of adhesions merely raises the question of whether penile functioning is being restricted. If he can urinate successfully and normal erections are not hindered, there is no reason to hurry nature. If he cannot urinate successfully and/or normal erections are hindered, that is medical need requiring intervention. (Such intervention does not automatically mean circumcision.)

It matters that this case began three years ago when M was 9. There is a difference between 9 and 12. Also, irregular readhesions will occur if the foreskin is forcibly separated from the glans before the adhesion naturally breaks. This is common among the children of parents who are ignorant of proper care of the normal (i.e. intact) penis.

Under no circumstances is it normal to break this adhesion at birth on a healthy foreskin and penis, as the bond must be forcibly broken to circumcise. The results can be bad, beyond the guarantee of scarring and loss of erogenous tissue.

Ellen averred that circumcision is a safe procedure, that there would be some minor discomfort for about three days that would not prevent M from carrying on normal activities, and that M's circumcision would greatly reduce M's risk of penile cancer and certain infections.

It is a safe procedure that causes injury to every male circumcised, as evidenced by the scarring, and occasionally leads to more serious complications, up to and including death. Who is the best judge of whether or not this inherent risk is acceptable in the complete absence of medical need?

The doctor's statement that circumcision would cause minor discomfort and a short healing period should be noted. The actual post-operative constraints from adult circumcision are little different, contrary to the scare tactics generally offered as an excuse to push the surgery onto children. This doesn't have a direct connection to this case, but Dr. Ellen is using standard arguments to treat a specific case, so it warrants mentioning.

Of course, no circumcision advocate's argument would be complete without the grand reliance on potential benefits against extremely minor risks. Remember, too, that those risks are almost universally based on behavior (e.g. smoking, promiscuity, lack of hygiene) rather than anatomy.

We agree with the trial court that the authority of the custodial parent to make medical decisions for his or her child, including decisions involving elective procedures and decisions that may involve medical risks, is implicit in both our case law and Oregon statutes.

Once again, Oregon already has a statue to forbid parents from imposing genital cutting on their daughters for any of the reasons the Court accepts here for male children. That is wrong. It violates Section 1 of the Oregon Constitution:

Section 1. Natural rights inherent in people. We declare that all men, when they form a social compact are equal in right: ...

I'm having trouble understanding any exception to that which excludes only the genitals of male minors. I don't doubt that the law allows it, but where it does, the law is a ass.

Mother, joined by amicus curiae Doctors Opposing Circumcision (DOC), asserts that there is no more important decision to make for a male child than to require that the child undergo permanent modification to his body, and argues that an evidentiary hearing is required to find out whether M objects to the circumcision. She also contends that an evidentiary hearing is required so that she may present evidence regarding the harmful effects and permanent nature of circumcision. Indeed, mother and DOC assert that, because of the significant medical risks associated with circumcision, M should not be circumcised even if he states that he wants to undergo the procedure.

I agree with the last sentence, although I have written that I will not object in this individual case if M specifically wishes to be circumcised. But the primary logic in that paragraph is so fundamental that every lower court that ignored it should be ashamed. Individual rights, individual rights, individual rights, individual rights. This is not complicated. I'm not an attorney and I can grasp that. No individual is another's property. It's elementary, despite attempts to make it appear more complicated and nuanced. Male children are treated as such, but that does not make it legitimate. History will not be kind on our long dalliance with barbarism.

In response, father, joined by amicus curiae American Jewish Congress, American Jewish Committee, Anti-Defamation League, and Union of Orthodox Jewish Congregations of America (collectively, AJC), argues that the trial court did not need to hold an evidentiary hearing, because M's attitude about whether he wants the circumcision is not legally significant. Father asserts that a child is not the decision-maker on such questions, any more than an infant who is circumcised. If the legislature had wanted a male child to have a say in whether he is circumcised, he contends, it could have adopted a statute to that effect, as it has done in other statutes such as ORS 109.610 (giving minors the right to consent to treatment for venereal disease without parental consent). Father also contends that the health risks associated with male circumcision are de minimus. In any case, father maintains that the affidavits he supplied to the trial court demonstrate that M does want to be circumcised.

Not legally significant. Again, what if a parent wanted to cut off a child's finger? The child's opinion would be legally significant then. There is no valid reason for an exception on the genitals of male children. It doesn't matter if the child is 17 minutes or 17 years old.

The father is an attorney. I have no doubt he is aware of the law against female genital cutting. Firing up the Way Back machine to yesterday, the legislature's silence on an issue is not the end of the discussion. Whenever the law and the constitution are in conflict, the constitution must wins. In other words, the law loses, legislatures be damned. Oversight does not grant legitimacy. The constitution guarantees equal protection. The law discriminates based on gender. The law is a ass.

For what it's worth, I doubt the males who suffer complications from the inherent risks of circumcision do not consider them trivial. He can never guarantee that M will not suffer a complication. As such, we're back to medical need. It is not necessary. Therefore, it is unacceptable to impose it. That is the only debate.

Finally, father and AJC argue that father has a constitutionally protected right to circumcise his son. They maintain that American Jews must be free to practice circumcision because it is and has been one of the most fundamental and sacred parts of the Jewish tradition. Father concludes that, if this court requires the trial court to hold an evidentiary hearing, we would usurp the role of the custodial parent and violate the First Amendment of the United States Constitution.

Lifting religious text above a constitution founded on principles of liberty is the way of theocracy. Worse, picking only the preferred requirements of a religious text is the worst possible intellectual dishonesty.

Slavery is in the Bible. We do not allow it. Polygamy is in the Bible. We do not allow it. Vigilante justice is in the Bible. We do not allow it.

And what of other religious texts? Do we start allowing any act that involves one person violating the rights of another, as long as it's printed in an old book that many people value? Tradition, sacred or not, is a claim made when principles contradict the desired outcome.

We conclude that, although circumcision is an invasive medical procedure that results in permanent physical alteration of a body part and has attendant medical risks, the decision to have a male child circumcised for medical or religious reasons is one that is commonly and historically made by parents in the United States.

What kind of mental gymnastics must one engage in to marry the pre- and post-comma statements into one argument? Liberty demands that we stop at the comma when there is no medical need. Regardless of need, nothing after the comma is valid.

If, however, the trial court finds that M opposes the circumcision, it must then determine whether M's opposition to the circumcision will affect father's ability to properly care for M. And, if necessary, the trial court then can determine whether it is in M's best interests to retain the existing custody arrangement, whether other conditions should be imposed on father's continued custody of M, or change custody from father to mother.

The qualification here leads me to believe this victory will be pyrrhic. Sure, the court is acknowledging that someone should've asked the boy¹ for his opinion on what happens to his body. But it is not saying that the court must deny the father's desire to circumcise his son. Even if the boy says he does not want his genitals surgically cut², the standard becomes whether or not forced genital cutting on the boy will impair the father's ability to continue raising his son. The Court is actively embracing the stupidity that, if he doesn't want it, he may still be treated like property. The Court considers permanent genital modification on a child no different in legitimacy than his father telling him he has to eat Brussels sprouts rather than chocolate. Our society is insane.

¹ His age is irrelevant. We can't ask infants, but we should. Since they can't give an answer, the only course of action is no action. Until he can ask for an "invasive medical procedure that results in permanent physical alteration of a body part and has attendant medical risks," do nothing while he is healthy.

² Some argue that a hospital circumcision is invalid as a Jewish rite because the surgery must be performed by a mohel.

What An Interesting Idea.

The Oregon Supreme Court announced its decision in Boldt and Boldt. I'm currently reading it, not that I can specifically offer anything in the way of legal analysis. But the conclusion is stunning from the perspective of individual rights.

We remand the case to the trial court with instructions to resolve the factual issue whether M agrees or objects to the circumcision.

"M" is the 12-year-old boy in the case. His foreskin, his opinion? What an original idea.

More later.

Update: Andrew Sullivan reaches the same basic conclusion.

January 24, 2008

I will have an opinion.

From Oregon:

A divorce dispute over whether to circumcise a 12-year-old boy will be decided Friday by the Oregon Supreme Court.

The nationally-watched case pits a father who converted to Judaism and wants his son to undergo the religious ritual, against his mother, an orthodox Christian who claims the boy doesn't want to be circumcised.

I've written about this in many posts already. I'm curious to discover whether or not the Oregon Supreme Court understands the fallacy of the Circuit judge's opinion that "the decision of whether or not a child has elective surgery, which this appears to be, is a call that should be made and is reserved to the custodial parent". Elective surgery is a very large scope. It would certainly be legally strange to continue the irrational stance of applying one standard to the penis and another to the labia and clitoris. But then, Oregon already embraces gender discrimination in its law against the mutilation of a minor's genitals.

I hope we get a broad precedent-setting ruling protecting males as females are already protected, but I'm not stupid. I am pessimistically cautious that we'll get a ruling in favor of the mother's argument. Hopefully the court will have the sense to at least go there, custodial parents "rights" be damned. More tomorrow, after the Court announces its ruling.

Update: My opinion is here.

Half of Newborn Americans Face Gender-based Discrimination

What's wrong with the title of this news story reporting on infant circumcision rates in the United States?

Half Of Newborn Americans Undergo Circumcision

That is not true because we discriminate against children based on gender. Half of newborn Americans are protected - by federal law - from needless cutting on their healthy genitals. Among the other half of newborn Americans (i.e. males), slightly more than half of them have their healthy genitals surgically reduced for non-medical reasons. The other half of unprotected newborn American males are still subject to their parents' whim regarding circumcision, as if cosmetic surgery is a legitimate decision belonging to parents.

January 23, 2008

Panicking exposes an ethical flaw.

This is the predictable near-end-result of embracing the irrational.

Rwanda has launched a campaign to encourage all men to be circumcised, to reduce the risk of catching HIV/Aids.

Digging a little deeper, according to Innocent Nyaruhirira, secretary of state for Aids prevention, the truth:

"We will start this campaign with the new born and young men in universities, the army and police."

Circumcision as an HIV prevention strategy is absurd when condoms and safe-sex are still necessary, but one target group is not like the others. Forcing circumcision on a child is a bizarre definition of encourage.

I will not pretend to be shocked. Even when leaving aside the glaring ethical violation of cutting the healthy genitals of a child, scarce medical resources will be used to circumcise those who will not be sexually active for a dozen or more years. Brilliant strategy.

But consider a few statistics. In 2000, 11% of Rwandan adults were HIV-positive. Over a period of years, traditional approaches to HIV prevention were implemented. In 2007, 3% of Rwandan adults were HIV-positive. Other than the obviously unfortunate reality that many HIV-positive adults have died in that period, the non-circumcision approach works. Why must those who will grow up to be responsible be judged irresponsible before they've had a chance to prove themselves? Why must they pay the price for a flaw they may not possess?

Coerced "protection" is morally inferior to the consequences of individual action, whatever the actual consequence.

January 22, 2008

WHO doesn't understand the definition of "healthy".

In an article in the New York Times on female genital cutting in Indonesia, here's the obligatory mention. I'm only surprised that it appears so late in the story.

Any distinction between injuring the cli