What about ethics?

I’m on vacation, so I shouldn’t be blogging this. However, vacation is the only reason I’ve waited as long as I have. William Saletan is wrong on circumcision. Consider:

For thousands of years, we humans have lovingly mutilated our children. We give birth to them, swaddle them and then cut their genitals. Some people condemn these rituals; others defend them. Now reports from Africa are shaking assumptions on both sides. Our mutilation of girls may be killing them. Our mutilation of boys may be saving their lives.

Read that with an ounce of logic and it’s clear where his analysis is lacking. The manner in which humans practice the two forms of mutilation dictates that, not the validity of the surgical procedures. We cut girls to an extreme not generally practiced on boys. But the qualitative comparison, the surgical alteration of a non-consenting child without immediate medical indication, is the same. The quantitative analysis so favored by those dismissing that comparison does not change its validity. Pretending that quantitative analysis alters that is the folly that offers protection to girls while boys must surrender healthy foreskins to avoid potential problems that will most likely never materialize.

In discussing the growing movement to protect boys legally, as girls are now protected in the United States by the Female Genital Mutilation Act, Mr. Saletan offers this challenge:

But scientific rebellions against religion have a nasty habit of becoming religions themselves. First come the myths. Last month, Dan Bollinger, director of the International Coalition for Genital Integrity (ICGI), launched Project: OUCH!, a “collection of first hand accounts” by victims of genital mutilation. The first account, written by Bollinger, described a recurring “flashback of my circumcision when I was three days old.” It was a moving story. But according to brain researchers, such memories at that age are impossible.

I’ve read Mr. Bollinger’s site, although I offer no opinion on the validity of his flashback. My only belief is that both sides should exercise skepticism. Until recently, accepted medical opinion stated that infants do not feel pain. However, the higher burden rests with those who wish to circumcise infants. Their position involves the permanent removal of healthy tissue without the consent of the patient. In any other medical decision, doctors would refuse to conduct such an operation. Yet, male circumcision gets a free pass, even though it is radical surgery. Whether it’s religion, societal norm, or potential benefits, supporters must exercise caution. The ethical implication must be included. It is most often ignored.

Then comes the ideology. Foreskin advocates say uncut men are “intact,” “natural” and “normal.” Circumcised men, by implication, aren’t. Technically, according to Doctors Opposing Circumcision, it’s up to you whether to “go through life with incomplete genitalia.” But what kind of man would choose that?

Uncut, or uncircumcised, implies that cut is the normal, correct state of the penis; the foreskin at birth is simply a defect to be removed. This is wrong. We do not say that clothes are undirty after we wash them. This is why you see [sic] after uncircumcised in my entries. They sound ridiculous, but unintact, unnatural, or unnormal better describe the circumcised penis. Circumcision is common, not normal. If that makes me guilty of ideology, fine. But, again, the burden of proof lies with those who wish to cut.

As for Mr. Saletan’s rhetorical question, I’m not sure how he can approach that question and then not challenge the assumption that male infant circumcision is reasonable. The fact that the majority of the intact adult population never needs circumcision, nor seeks it, is telling. So why do we believe that it’s reasonable to circumcise male infants? (Mr. Saletan returns to this in a few paragraphs.)

Half the time, anti-circumcision activists talk like antiabortion activists. They’re pushing federal legislation that would impose a prison sentence of up to 14 years on anyone who “cuts or mutilates the whole or any part” of the foreskin of a boy younger than 18. (Call it the “partial bris” bill.) They’re planning lawsuits to intimidate doctors and ban infant circumcision.

The language Mr. Saletan mocks is already in the Female Genital Mutilation Act. Worth noting.

The rest of the time, they talk like radical feminists. They’re outraged that we deplore female mutilation but tolerate male circumcision. They call this sex discrimination and a violation of the Constitution’s equal protection clause. The ICGI has even proposed an international legal code equating removal of the foreskin with removal of the clitoris.

Have these people lost their heads?

“Guilty”, but that’s not my point for excerpting that text. Removal of the foreskin is not equivalent to removal of the clitoris. I do not need to push that fallacy to make my point. Removal of the foreskin is similar to removal of the clitoral hood or the labia¹. Type I female genital mutilation without excision causes no more damage than male circumcision². Should we allow that, since quantitative analysis seems to be all that matters? The answer seems to be yes, unless supporters of male infant circumcision wish to finally stop arguing the foolish notion that female circumcision is heinous, while male circumcision is parental choice. Hypocrisy or female genital mutilation. Supporters of male infant circumcision choose one or the other with their stance.

The stakes in that question are becoming deadly serious. Of the 5 million people who contracted HIV last year, two-thirds lived in sub-Saharan Africa. Four years ago, the U.S. Agency for International Development analyzed 38 studies, most in Africa, and concluded that circumcised men were less than half as likely as uncircumcised men to get HIV, apparently because of the susceptibility of foreskin. Last fall, a randomized controlled trial in South Africa found that circumcision reduced female-to-male transmission of the virus by 60 percent. “Male circumcision provides a degree of protection against acquiring HIV infection, equivalent to what a vaccine of high efficacy would have achieved,” the authors wrote. It was, they observed, “the first experimental study demonstrating that surgery can be used to prevent an infectious disease.”

It’s easy to “win” your argument by throwing out impressive statistics. Consider:

RESULTS.–We observed one probable instance (1%) of female-to-male transmission compared with 20% transmission rates in the female partners of infected men. All couples were sampled in the same way. Male index cases were more likely to be symptomatic than female index cases. CONCLUSION.–The odds of male-to-female transmission were significantly greater than female-to-male transmission. The one case of female-to-male transmission was unique in that the couple reported numerous unprotected sexual contacts and noted several instances of vaginal and penile bleeding during intercourse.

I don’t offer this as a definitive gotcha, only as an indication of how statistics may not tell the entire story. The 60% reduction in HIV transmission number is fascinating, but it must be considered in the proper context. Female-to-male transmission is not the most common form of transmission. Why is it acceptable for supporters of circumcision to use the least common³ form of sexual transmission as the sole basis for a radical policy, while circumcision opponents can’t use the least common form of female genital mutilation as the basis for comparing the qualitative and ethical similaritie
s of the two procedures? My position is not the crazy position.

Think about that: surgery as a vaccine. Drug researchers would kill for an HIV vaccine half as effective as circumcision. Condoms and abstinence often aren’t effective because they require diligence. Circumcision works more reliably for the same reason that foreskin enthusiasts hate it: It lasts forever. Using the new data, scientists estimate that over the next 20 years, circumcision in sub-Saharan Africa could prevent 6 million infections and 3 million deaths.

I must beat the personal responsibility drum again. Boys 1 through 999 shouldn’t have to lose a foreskin because boy 1,000 can’t be bothered to wear a condom. The diligence argument is collectivist nonsense, pushing the benefit to the group above the protection of the individual. The Constitution has no exception voiding its protection of individual rights just because irresponsible behavior may occur.

What do you do when mutilation turns out to save lives? Anti-circumcisionists can’t bear it. Years ago, they denied the HIV-prevention effect. When evidence from Africa defied them, they changed the subject to Europe. When evidence from Europe defied them, they changed the subject again. Some say a link between circumcision and HIV can never be proved. Others ignore it. Others insist it’s unethical and false. It can’t be true. It’s heresy.

Mr. Saletan is throwing everything and hoping something sticks. He provides many links to anti-circumcision arguments in the Slate version of his essay. I’ve probably duplicated some of the arguments he tries to diminish. I’m not going to rehash them here, but instead offer the suggestion that doubters use the search feature on the main page of Rolling Doughnut to review what I’ve written about circumcision. Poke holes if you can. I have not denied any results, as Mr. Saletan accuses (indirectly, of course, for he did not link here), nor do I feel denial is necessary..

The strongest argument against circumcising babies to prevent HIV is that they’re too young to consent. But we vaccinate babies all the time. Should we treat circumcision like a vaccine? At clinics across southern Africa, men are lining up, pleading to be circumcised. They want protection. Can we assume their sons would want the same thing?

The comparison of circumcision and vaccination is a diversionary tactic with no basis in reality. We vaccinate against communicable diseases, not individual choices. The former is a public health issue (although we still allow parents to decline), while the latter is purely individual. As such, there is a reasonable explanation for parental decision on vaccinations, while limiting there choice on circumcision to medical necessity. Lack of diligence does not result in polio. Many of the alleged protections for male circumcision have less invasive solutions (i.e., the same ones we use for females), but they also have an element of parents educating children about responsibility and consequences. That is especially true of HIV. But it’s easier to cut.

To the specific example of men lining up, this is wonderful if they choose circumcision because their behavior or their perceived threat of exposure puts them at risk. I have never argued that adult circumcision should not be allowed. I’ve gone so far as to say that men should choose to have themselves circumcised if they believe it will help. Choice is the ultimate issue here. Those men have it. Their sons, and now with another bogus justification, our sons, do not. The lack of a stampede among intact European and American men to have themselves circumcised suggests that their sons would not want the same thing. The child’s cries during circumcision are also a reasonable indicator of his wishes.

Next weekend in Seattle, critics of genital mutilation will convene an international symposium on circumcision. The program lists 40 sessions. Not one mentions AIDS or male circumcision in Africa. Something’s sorely missing from this conversation, and it ain’t foreskin.

That symposium is why Seattle is on my travel itinerary this week. Even though I want to hear everything discussed on Friday, I’m willing to step out at 3:00pm PST for however long it takes to explain to Mr. Saletan “Traditional Male Circumcision in West Timor, Indonesia: Practices, Myths, and their Impact on the Spread of HIV/AIDS and Gender Relations”. That’s on the schedule at 2:40pm. It’s not listed on the schedule, but I’m sure HIV will come up at 4:40pm on Friday during “Circumcision in the Mass Media”. I suspect “Coding, Reporting, and Analyzing Circumcision Data” on Saturday at 9:00am will include some discussion of HIV, as well.

Mr. Saletan thought he was making a point because the discussion does not center on AIDS in Africa. However, he does not indicate that his support for male infant circumcision as an HIV preventive is limited to Africa. Surely he does not believe the two cultures are the same. As such, he is guilty of the same omission of facts that color his argument with shades of grey. Instead of making his point, he demonstrated how circumcision supporters are leaving the foreskin and its functions out of the conversation on circumcision. HIV/AIDS is only one aspect of this discussion.

¹ This editorial by Dr. Paul Tinari posits the following:

The cells of the labia are also susceptible to HIV infection, so what role does female circumcision play in reducing the rate of HIV infection?

I don’t have time to find studies verifying this claim, but it’s worth considering. If it’s possible, should we fund research here? If research finds a link, should we repeal the Female Genital Mutilation Act and begin circumcising infant females? I know it’s preposterous, so why isn’t male circumcision objectionable? Neither or both are the only choices. I choose neither.

² I also have no need to push the belief that Type I without excision is common. It is not. Most female genital mutilations are severe. I offer this example only as proof of our hypocrisy in ignoring any qualitative analysis. For more info on the various types of FGM, click here.

³ I’m excluding female-to-female, even though I assume it’s the least common method of transmission. Since it does not involve a penis, it is not pertinent to this discussion.