An extremely long rebuttal

When I wrote this post, I hoped for a reply. Archie at Archontan responded with a few answers as to why male and female circumcision are not equivalent, which are important to him as a clarification that permits the former and not the latter. As you should expect, I disagree. This discussion requires two distinct lines of debate, but they run parallel and intersect in conclusion. I’ll deal with them separately in my attempt to address his response.

Before beginning my rebuttal, I must state that I understand Archie is not calling for universal circumcision of male infants in America. My responses are more geared to how some individuals have irresponsibly suggested that the findings of recent studies on the foreskin and HIV are as relevant to the United States as they are to sub-Saharan Africa. Archie has made the opposite claim, that his defense of male circumcision should not be read as a call for universal circumcision in America. It is an important note, one I made here. It bears repeating, as my arguments here are not meant as combative against Archie, or anyone else who supports parental choice regarding non-medically indicated circumcision, in this case to lower the risk of female-to-male HIV transmission through sexual intercourse. I aim only to refute the logic structure that supports such parental choice, particularly in the United States, but also in Africa. End of disclaimer.

First, the medical consideration for foreskin removal as an HIV preventative is incomplete. I do not mean to deny the findings of the study linking removal of the foreskin to reduced female-to-male HIV transmission. I accept that finding as reasonable conclusions; less skin, less exposure. As bizarre as implementation is, I’d be a fool to pretend otherwise. But the results are hardly unequivocal, as Archie challenges. From the study linked (indirectly) by Archie and (directly) by William Saletan, consider the conclusion on the number of HIV infections that routine circumcision could prevent in Africa:

This analysis is based on the result of just one RCT, but if the results of that trial are confirmed we suggest that MC could substantially reduce the burden of HIV in Africa, especially in southern Africa where the prevalence of MC is low and the prevalence of HIV is high. While the protective benefit to HIV-negative men will be immediate, the full impact of MC on HIV-related illness and death will only be apparent in ten to twenty years.

The line of demarcation in that paragraph is important. Too many want to focus on the projections, estimated based on the Auvert study. However, what’s stated before the first comma is vital. One randomized controlled trial does not provide scientific proof, so it’s premature to call the results unequivocal. Wishing is not enough. But I quibble over distractions.

The proper medical analysis must include the risks of circumcision. Like any surgery, these are real every time a doctor cuts into a patient’s flesh. With every circumcision the boy being cut faces the possibility of complications, including, but not limited to, excessive bleeding, infection (HIV included, since aseptic procedures aren’t common in Africa), penile damage, partial or complete amputation, and death.

The frequency of complications is open for discussion, but whatever the actual complication rate, they exist. I’ve been involved in discussions where those favoring circumcision comprehend “potential benefits and potential complications” as “potential benefits and potential complications.” No. Potential is the key word on each side. As such, a thorough cost/benefit analysis must be involved. How much will we spend treating those who get infected with HIV? How much will we spend circumcising every male? How much will we spend correcting surgical complications? How will men circumcised as infants view their complications, should any arise? Will the greater good of HIV-protection satisfy their objections? The list goes on. In the “circumcision prevents HIV” debate, it has not begun. We have intellectually punted the notion that male and female genitalia are qualitatively equal and deserve equal protection.

The ethical debate is where support for circumcision of non-consenting individuals for HIV prevention most readily fails. What is medically possible and what is medically acceptable are not the same thing. If the foreskin link to HIV bears out, we’ll readjust our present justifications, beyond that which has already occurred, and continue circumcising our infants. But why stop there? If we remove the breast tissue of infant girls, they’ll face a significant reduction in breast cancer. Considering it’s much more likely for a girl to face breast cancer in her lifetime than it is for a man to face any such catastrophic disease affecting his foreskin, there is medical validity for taking such an action.

That scenario is preposterous, and I do not intend it as a policy recommendation or anything beyond rhetorical. I intend it to show that life has risks inherent in normal anatomy. We chase potential problems without indication because we fear disease. We make assumptions not based in reality, allowing radical surgery to take hold as a valid response to what our friend’s cousin’s boss’s third ex-husband faced one time. It’s cultural stupidity for which boys, and boys alone, must sacrifice a healthy, functional part of their genitalia under the surgeon’s knife.

Rational thought exists. As Archie states:

In the West, there is a small population of girls and women who have had their clitoral hoods removed or modified for strictly medical reasons, due to congenital defects and other problems.

Congenital defects and other problems are all we allow as reason for female genital cutting. I do not believe anyone would disagree with that as ethically sound and a perfect limitation. Why is it not just as ethically sound to limit male circumcision to those infants with a congenital defect of the prepuce, or another foreskin problem that can’t be solved with less invasive means? It can’t be because we can medically prevent potential medical problems in the future, unless we wish to revisit the vicious circle of the infant mastectomy argument. I can imagine no scenario of non-medical necessity in which the child’s individual rights exclude his foreskin from this ethical evaluation.

When reading his original post, I did not believe that Archie suggested hoodectomy as a valid possibility for consideration, despite its obvious anatomical comparison. His preferred comparison is qualitatively logical:

Also, during intercourse that large surface area of mucosal tissue [inner mucosal surface of the foreskin] has prolonged exposure to the partner’s fluids and tissues. In female sexual anatomy, the vulnerable mucosal tissue with a large surface area and prolonged exposure to the partner’s fluids is not the clitoral hood but the vagina. In other words the vagina is, as far as HIV transmission is concerned, the functional analogue of the male foreskin. Besides male circumcision, there is no surgical means to signific
antly reduce the vulnerability of the receptive partner, whether female or male.

Again, duly noted, with agreement. But why is it the man’s duty to give up his foreskin to protect both of them? Neither of them has an excuse to abdicate responsibility to practice safe sex, whether through choosing monogamy or condoms, just because a doctor cut away his foreskin. Yet, if we assume the man must lose his foreskin at his parents whim, is it not reasonable to assume that they should decide whether or not to trim their daughter’s labia, since that could play a role in HIV infection? I know I’m venturing back into the comparisons between male and female circumcision that many dismiss, but the only criteria I read here is mucosal tissue directly involved in sexual intercourse. If that’s not narrow enough, all I can guess is that ease of access for the doctor’s scalpel is the vital deciding factor. If so, that’s dumb.

Granted, female genitalia is mostly internal, especially in infancy. But so is male genitalia. To circumcise a male infant, his foreskin must be forcibly separated from his glans. The synechiae keeping the two structures together will not separate naturally for several years at least. Where is the distinction that allows tearing the foreskin from the glans but prohibits meddling with female genitalia? The basic structure of the infant penis indicates that the foreskin is not meant to be retracted, probed, or amputated.

Carrying the anatomical structure back into the ethical realm, I wrote this last month:

Children do not engage in sex until well beyond the period in which they can be taught responsible behavior and an understanding of consequences. Their intact genitals do not expose them to HIV. They do not need to fret over whether or not condoms will provide them adequate protection. For each boy, HIV will not jump onto his penis, crawl in between his glans and foreskin, and burrow through the susceptible cells. His intact foreskin will not create a public health crisis.

Nor will it create a personal health crisis for the boy. So what’s the hurry?

I do not favor banning¹ male circumcision, for that position is far too generalized. I favor banning the forced circumcision or genital cutting of non-consenting individuals, male or female. Again, Archie stated that he is not calling for universal male circumcision. It is an important point, and one I did not miss, despite any such implications in this post. My primary focus is male infant circumcision in America, of course. What adults choose to do to their own body is up to them. If an intact adult male in America or Africa believes himself to be at risk for HIV because he is intact, and he thinks his foreskin isn’t worth the potential infection risk, he should have the surgery. That’s conveniently the best time, as well, since his foreskin has separated from his glans. He can provide input to his doctor on how much foreskin to take or leave, as well as how to treat his frenulum.

But no one has the right to impose circumcision on another, no matter how many men are lining up to have the surgery performed on themselves². With respect to infants, parents are guardians, not property owners. The quantitative comparison between male and female circumcision most often provides a tremendous disparity, which is why girls are protected in America. What is not recognized is their qualitative equivalence. Medically unnecessary surgery on a non-consenting individual is wrong, no matter how “minor” the procedure or well-intentioned the motive. The proper perspective is not what the circumcision might prevent. The proper perspective is what the child needs. He does not need genital surgery. Should the need arise with his future self, that is the time for him to make or not make that decision.

¹ This link is much more appropriate for the Ninth International Symposium on Circumcision, Genital Integrity, and Human Rights than the link Archie provides. As I said in my rebuttal to William Saletan’s recent Slate article, I attended the symposium. I consider myself qualified to judge the applicability of a news story about the symposium to the actual symposium. And if attending the symposium brands me a kook, so be it. My writings already indicate that I think outside the mainstream on this topic. I can still be correct outside the mainstream.

² I addressed this point in my rebuttal of Mr. Saletan.