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.

Is There Any Choice Parents Can’t Make?

I haven’t written on Roman Polanski’s arrest because everything worth saying is so blindingly obvious that those who need to hear are likely devoid of any capacity for understanding it. Still, one point thrown around bothered me most. The following excerpt from a New York Times article discussing cultural changes since the rape of a 13-year-old sums up the point I witnessed in more than one excuse for Polanski (emphasis added):

A 28-page probation officer’s report completed in September of that year presented a broadly sympathetic portrait of Mr. Polanski and his behavior, even while acknowledging that the victim, Samantha Geimer (who has since publicly identified herself), had offered grand jury testimony of forcible rape.

Submitted by the acting probation officer Kenneth F. Fare, and signed by a deputy, Irwin Gold, that report, which recommended against further jail time, said “the present offense appears to have been spontaneous and an exercise of poor judgment by the defendant.”

In a further conclusion that appeared to shed blame on the victim, it said, “There was some indication that circumstances were provocative, that there was some permissiveness by the mother,” who had allowed Ms. Geimer to spend time with Mr. Polanski. And, in a conclusion that might particularly jar readers today, it pointed toward evidence “that the victim was not only physically mature, but willing.”

I do not want to meet the sort of person who would suggest that parents may consent to the rape of their children. Anyone who suggests such a right exists is a barbarian. It doesn’t, because children are not property.

**********

Posted without comment, I agree with every word of this assessment of the case (and the NYT article) by author Lauren McLaughlin, titled “She Was an Eight Grader.” A choice excerpt:

They don’t mention the drugs he gave her, drugs with very specific muscle-relaxing properties, mind you. They don’t mention that she said no repeatedly. They don’t mention that, after fleeing his sentence, Polanski immediately took up with another minor, Nastassja Kinski. If there’s a clearer case of unrepentant pedophilia, I’m not aware of it.

Nor is Polanski’s pedophilia in anyway mitigated by the fact that he seems to think that everyone wants to have sex with young girls. Rather, it’s a sign of the decrepit company he must have kept. And, perhaps, of the decrepit leniency with which sexual assault used to be treated.

For this reason, it irks but does not surprise me that people like Martin Scorsese, Woody Allen, and Terry Gilliam signed that petition. But why did Tilda Swinton, Darren Aronofsky, and Alexander Payne sign it? Are they aware of the actual crimes they’re so anxious to pardon? And if so, what exactly would Polanski have had to do to this eighth grader to disqualify himself from their forgiveness?