Circumcision – Page 3 – Rolling Doughnut

Education Without Understanding

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

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

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

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

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

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

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

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

Just a reminder…

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

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

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

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

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

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

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

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

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

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

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

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

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

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

¹ Title quote reference here.

Massachusetts Will Debate The Right to Bodily Integrity

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

…

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

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

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

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

Thumbs Down:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Science Requires Ethics, Part 3

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

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

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

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

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

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

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

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

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

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

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

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

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

… Now consider this:

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

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

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

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

Next, on circumcision versus vaccination:

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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.

Science Requires Ethics, Revisited

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

… It’s a shame that he mischaracterises me as a “pro-circumcision advocate”, though (I’m pro-parental choice, not pro-circumcision).

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

… 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 beca
use 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.

Hanna Rosin Is Still Wrong On Circumcision, Revisited

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

These studies are not entirely relevant to the U.S. They apply only to female-to-male transmission, which is relatively rare here. But the results are so dramatic that people who work in AIDS prevention can’t ignore them. Daniel Halperin, an AIDS expert at the Harvard School of Public Health, has compared various countries, and the patterns are obvious. In a study of 28 nations, he found that low circumcision rates (fewer than 20 percent) match up with high HIV rates, and vice versa. Similar patterns are turning up in the U.S. as well. A team of researchers from the CDC and Johns Hopkins analyzed records of over 26,000 heterosexual African-American men who showed up at a Baltimore clinic for HIV testing and denied any drug use or homosexual contact. Among those with known HIV exposure, the ones who did turn ou
t 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

Science Requires Ethics

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

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

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

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

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

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

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

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

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

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

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

Continuing:

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

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

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

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

Continuing:

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

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

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

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

Nancy McDermott Is Wrong On Circumcision

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

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

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

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

She continues:

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

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

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

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

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

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

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

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

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

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

Continuing:

It is striking that midway through Epstein’s article the CDC’s proposal to ‘promote’ infant circumcision mysteriously transforms into a plan to ‘m
andate’ 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.

Religion By Scalpel Is Not A Parental Right

Andrew Sullivan weighs in on the CDC circumcision mess:

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

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

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

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

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

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

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

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