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.

Posted by Tony | Permalink | Comments (1)

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.

Posted by Tony | Permalink | Comments (37)

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.

Posted by Tony | Permalink | Comments (0)

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.

Posted by Tony | Permalink | Comments (2)

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

Posted by Tony | Permalink | Comments (0)

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.

Posted by Tony | Permalink | Comments (9)

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.

Posted by Tony | Permalink | Comments (1)

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.

Posted by Tony | Permalink | Comments (2)

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

Posted by Tony | Permalink | Comments (2)

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.

Posted by Tony | Permalink | Comments (2)

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.

Posted by Tony | Permalink | Comments (4)

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?

Posted by Tony | Permalink | Comments (2)

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.

Posted by Tony | Permalink | Comments (0)

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.

Posted by Tony | Permalink | Comments (5)

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.

Posted by Tony | Permalink | Comments (17)

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.

Posted by Tony | Permalink | Comments (4)

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.

Posted by Tony | Permalink | Comments (0)

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"?

Posted by Tony | Permalink | Comments (0)

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.

Posted by Tony | Permalink | Comments (2)

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.

Posted by Tony | Permalink | Comments (0)

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.

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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.

Posted by Tony | Permalink | Comments (9)

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.

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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.

Posted by Tony | Permalink | Comments (0)

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.

Posted by Tony | Permalink | Comments (4)

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.

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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.

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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.

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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.

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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.

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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.

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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?

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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.

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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.

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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.

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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.

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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.

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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.

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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.

Posted by Tony | Permalink | Comments (150)

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.

Posted by Tony | Permalink | Comments (0)

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.

Posted by Tony | Permalink | Comments (2)

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.

Posted by Tony | Permalink | Comments (0)

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.

Posted by Tony | Permalink | Comments (0)

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.

Posted by Tony | Permalink | Comments (3)

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.

Posted by Tony | Permalink | Comments (0)

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.

Posted by Tony | Permalink | Comments (0)

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.

Posted by Tony | Permalink | Comments (0)

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.

Posted by Tony | Permalink | Comments (1)

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.

Posted by Tony | Permalink | Comments (0)

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.

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.

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[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.

Posted by Tony | Permalink | Comments (8)

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.

Posted by Tony | Permalink | Comments (1)

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.

Posted by Tony | Permalink | Comments (1)

Last week I saw both of these Tom Toles editorial cartoons, but never together.

And:

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.

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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.

Posted by Tony | Permalink | Comments (1)

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.

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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?

Posted by Tony | Permalink | Comments (3)

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"?

Posted by Tony | Permalink | Comments (1)

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.

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.

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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.

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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.

Posted by Tony | Permalink | Comments (3)

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.

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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.

Posted by Tony | Permalink | Comments (6)

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.

Posted by Tony | Permalink | Comments (1)

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.

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?

Posted by Tony | Permalink | Comments (2)

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.

Posted by Tony | Permalink | Comments (5)

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.

Posted by Tony | Permalink | Comments (0)

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.

Posted by Tony | Permalink | Comments (0)

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.

Posted by Tony | Permalink | Comments (2)

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.

Posted by Tony | Permalink | Comments (1)

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.

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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.

Posted by Tony | Permalink | Comments (1)

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.

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