Category: Ethics

Flawed Circumcision Defense: Mitchell Warren

Mitchell Warren, the Executive Director of AVAC, penned an essay at the Huffington Post titled The “Best Hope” for AIDS Vaccine Advocacy. If it was just that, it would be fine. It’s not just that because it never is, although it takes digging beyond the article itself to find the problem.

He begins this essay about searching for an HIV AIDS vaccine:

There is growing global momentum behind the call to begin to end the AIDS epidemic using the scientifically-proven options available today. These include voluntary medical male circumcision, antiretroviral therapy (ART) — which dramatically reduces risk of HIV transmission between stable sexual partners — and prevention of pediatric infection during pregnancy, delivery and breastfeeding. If taken to scale with resources and urgency, these core components of combination prevention, along with other key prevention interventions, can save lives, prevent new infections and lower the price tag for the global AIDS response over the long term.

Well, sure, if we’re talking voluntary medical [sic] male circumcision, there isn’t an immediate problem. Such a strategy works to re-enforce and extend infant male circumcision in the long-term, and that needs to be addressed. But, by itself, voluntary medical¹ non-therapeutic male circumcision is a choice an individual may make for himself.

That’s never where it ends. AVAC describes itself (emphasis added):

Founded in 1995, AVAC is a non-profit organization that uses education, policy analysis, advocacy and a network of global collaborations to accelerate the ethical development and global delivery of AIDS vaccines, male circumcision, microbicides, PrEP and other emerging HIV prevention options as part of a comprehensive response to the pandemic.

Its focus on ethics is so robust that it randomly drops voluntary from “voluntary medical male circumcision” on its circumcision page. Its focus on ethics is so sincere that AVAC once issued a press release quoting Mr. Warren supporting:

“Research and dialogue are also needed now to explore the feasibility of rolling out infant circumcision. This approach will not show immediate benefits in terms of HIV incidence but can minimize risks and could be a highly cost-effective implementation strategy over the long term.”

To be fair, that press release is more than five years old. But the site also includes a link to a 2010 paper co-written by Brian Morris titled, “The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV”. And the Women’s HIV Prevention Tracking Project (WHiPT), a collaborative initiative of AVAC and the ATHENA Network, released a report (pdf) in December 2010 titled “Making Medical Male Circumcision Work for Women”. Question: why is voluntary missing in voluntary medical male circumcision? The report, as suggested by the missing “Voluntary”, is full of YAY INFANT CIRCUMCISION. For example, on page 9, under Next Steps for WHIPT Advocacy based on the findings:

Over the next year, WHiPT teams will execute advocacy plans based on their findings. Actions include:

  • …
  • Investigating the benefits and disadvantages of infant male circumcision

So, AVAC’s notion of ethics includes the ability for one person to “volunteer” another person for non-therapeutic surgery. I’m not surprised. It’s page on ethics includes:

The term ethics addresses ideas of right and wrong and with moral duty and obligation. Research ethics address “rights” and “wrongs” surrounding research that uses human participants to find answers to scientific questions. The primary focus of ethics guidelines for research in humans is safeguarding the rights, dignity, and health of the trial participant.

What about the ethics of applying the findings of research to non-consenting, healthy individuals? That is also a valid question that AVAC is apparently willing to ignore. Or should I read its position to mean these ethically-developed strategies are to be applied globally without further concern for ethics in applying those strategies? My analysis would be irrelevant in that reading. Of course, AVAC would still be very unethical, but my analysis would be wrong. I’m not that cynical, so I don’t read it that way. Onward.

The WHiPT report continues with its recommendations for Kenya (page 15):

The Ministry of Health should consider the integration of MMC for infants into the maternal and child health facilities, given the long-term benefits as well as the safe and inexpensive nature of the procedure.

I’ll ask again: why is the “V” missing in VMMC? Of course it wouldn’t make sense when talking about infant circumcision because that’s not voluntary. But the ethical position is to drop infant circumcision, not voluntary. The latter is just a matter of convenience in pursuit of an improperly-stated goal. (An improperly-stated goal could also be called “lying”.)

In its Uganda findings (page 55):

Almost one-third of the respondents said they would circumcise their infant boys if MMC were protective against HIV (33.3 percent for Kampala and 27.8 percent for Kapchorwa).

From its conclusion and recommendations for Uganda (page 57):

From the documentation, it is clear that women are aware of traditional/religious male circumcision but have little knowledge of MMC and its benefits to them. On the same note, women are not empowered in decisionmaking around MMC—with either their spouses or their infants. Policy makers should consider the social and gender implications of MMC in the community, if it is to be appreciated and beneficial to both men and women.

MMC acceptability and use in communities revolves around promotion, advocacy and sensitization efforts undertaken by the government, implementers and advocates.

  • Government and advocates must provide increased sensitization of women, with enough clear information about MMC before the community is prepared for its uptake.
  • Government, advocates and community leaders need to address the myths and bring facts about MMC with evidence-based information to communities.
  • Government and implementers must develop an MMC package that will integrate sexual and reproductive health with gender equity and empower women to get involved in decision-making, especially on condom use.
  • Implementers must impart knowledge and skills in decision-making regarding the circumcision of their male infants.

The “V” is missing everywhere. I’m starting to think the “V” key must be broken on every keyboard AVAC to which AVAC has access. That, or they only care about circumcision without regard to the ethics of voluntary action.

For further demonstration of the point, from the findings and recommendations surrounding the conflation of voluntary medical male circumcision and female genital mutilation, the report states (page 8):

• Advocates must monitor efforts to clarify the distinction between MMC and FGM.

There are distinctions in degree, which is what the researchers intend as proof that the difference is in kind. They are wrong, but temporarily, let’s accept their mistake as valid. Even with that requirement, there is one distinction between MMC and FGM that can’t be made, despite the group’s expectation that this distinction is obvious. Neither MMC nor FGM is voluntary. Both are forced on the recipient (i.e. victim) by another person. If the recommendation focused on the difference between VMMC and FGM, then the distinction would blink in neon. But they can’t include that because the entire premise of infant circumcision requires a complete rejection of the ethics of voluntary without regard for the defensibility of that rejection.

Basically, it’s clear that AVAC cares about the ethics of circumcision only as far as it’s useful in pushing circumcision. Where ethics permit circumcision, the concept matters. Where ethics reject circumcision, just drop the “V”. Circumcision is an AVAC objective, not ethical circumcision.

¹ I strike medical because the term advocates are looking for is medicalized, or something implying a sterile facility with modern surgical tools. I assume medical is also meant to convey the pursuit of potential benefits, but that too conveniently omits the ethical aspect of non-therapeutic circumcision. Thus, I have no interest in promoting loose wording.

Economic Principles Applied to Circumcision

I’m a huge fan of economics because it provides useful, widely-applicable lessons. Economist David Henderson created a list of The Ten Pillars of Economic Wisdom that is quite useful. Several of the principles apply directly to the issue of genital integrity. The principles obviously connected to the basic human right of genital integrity, from the current version (originally published in The Joy of Freedom: An Economist’s Odyssey):

1. TANSTAAFL: There ain’t no such thing as a free lunch.

Circumcision is commonly sold in the U.S. with a long list of benefits and a tiny list of supposedly rare risks. The challenge is that the former is only potential and the latter is incomplete. There is no such thing as a free lunch. Circumcision is more than a bunch of benefits in exchange for “a useless flap of skin”. In addition to the inherent risks of surgery, circumcision has permanent costs that last long beyond the surgery itself. This is what’s ignored. Most advocates of non-therapeutic child circumcision omit this. (Brian Morris is probably the most egregious offender on this point.) They treat the surgery as a free lunch. “Look at the potential benefits” they say. Even this, which is better than most lists, omits the full range of costs. There is no discussion of the mechanical change. There is no discussion of the foreskin as a normal anatomical structure or what’s lost. It’s just ignored, as if it’s not a cost. This omission is incorrect. (This is related to another economic principle.)

2. Incentives matter; incentives affect behavior.

The most obvious example is the third-party payment system within the United States that generally pays for non-therapeutic circumcision of children. Parents don’t see the full financial cost because it’s spread out among the full range of insured Americans. It’s as if it’s a free lunch because the direct cost is hidden.

This is also seen with Medicaid. Where it’s not funded by the state, fewer low-income parents impose non-therapeutic circumcision on their sons. (I reject the nonsense offered by advocates like Dr. Edgar Schoen¹ and Colorado State Senator Joyce Foster – for reasons related to several of these economic principles – when they say Medicaid funding is a matter of social justice.)

As an aside, I do not accept the argument that a single-payer government insurance system in America would automatically result in the near-extinction of non-therapeutic circumcision in America, as it has in a country like England, by removing the financial incentive. I’ve long voiced a level of skepticism on this for reasons influenced by this economic principle. Incentives matter. The hidden financial cost of circumcision is not the only incentive in America. The idea that circumcision is “patriotic” (to cite Schoen, among several) rests on a non-financial incentive. The fear that family, classmates, and/or future sexual partners will shun an intact male is an incentive. These are cultural and will not disappear if the only change in society is that parents will carry the full financial cost of imposing circumcision on their (male only) children. I’ve encountered too many examples of parents complaining that they “have” to pay for their son’s unnecessary circumcision because their insurance plan won’t cover it to think otherwise.

6. Every action has unintended consequences; you can never do only one thing.

This is related to the no free lunch principle. Parents and medical professionals think that allowing proxy consent on this involves doing what’s best for their son. Parents who circumcise are assumed to achieve this – and only this – outcome. However, the action eliminates the child’s personal choice. That is not generally intended, on the “parents are well-intentioned” fallacy that ignores the act of circumcision. But circumcision is not just reducing risk X or whatever argument parents use. It’s also whatever the child decides about circumcision. Perhaps his opinion will align with his parents’. Perhaps not. Either way, his choice is gone.

Also, the funds and labor used for circumcision are no longer available for therapeutic treatments or other pursuits. This is an unintended consequence.

7. The value of a good or a service is subjective.

This is the key point here. This applies to all circumcisions, but with non-therapeutic circumcision, it’s especially true. There is no objective need, no reason to impose this on someone who can’t consent. The value of the intervention rests with the recipient. Again, perhaps his opinion will align with his parents’, but perhaps not. Society permits (and often encourages) parental proxy consent. The value is placed exclusively on the parents’ subjective valuation of the potential benefits and (often ignored) costs of non-therapeutic circumcision. The child’s possible objection is ignored in favor of his parents’ preferences about his body. In my case, my parents paid for a circumcision that I wouldn’t choose to accept if I were paid an enormous amount of money to undergo the procedure. Their valuation doesn’t match mine for the service.

These principles help make the ethical case. A permanent, non-therapeutic alteration should never be imposed on someone who does not consent.

¹ Dr. Schoen, especially, since he writes “[t]his means that many poor families are unable to choose to receive a circumcision…”. The family doesn’t receive the circumcision. The child does. Dr. Schoen’s position on the ethics of non-therapeutic circumcision is idiotic and untethered from anything other than is subjective valuation. As economic principle number seven shows, the valuation of everyone other than the patient is irrelevant in the imposition of circumcision.

Sexual Control: Making a Permanent, Unnecessary Decision for a Child

It’s rare to find a blatant attempt to explore justifications for the use of male circumcision as a form of sexual control. From Thursday’s debate on SB12-090 (pdf) within the Colorado House Health and Environment Committee, State Representative Sue Schafer directed a request to Dr. Jennifer Johnson. Dr. Johnson testified against the bill, specifically, and child circumcision, generally. Within Dr. Johnson’s opposition, she discussed the nerve endings in the foreskin lost to circumcision. Rep. Schafer asked (audio, excerpted from the legislature’s archive):

Rep. [Lois] Court said earlier “there are no dumb questions”, and that we will speak in a respectful manner, but I’m concerned about the rate of teen pregnancy, the rate of date rape, sexual violence, and when you talk about more nerve endings in the penis, in the foreskin, I’m just wondering if there’s any risk of more sexual activity among young men, more male irresponsibility, so if you’d be good enough to comment on that.

That question isn’t dumb. It’s offensive and insulting. Her underlying implication is that, if non-therapeutic male circumcision could be shown to lower the occurrences of what she’s concerned about, that would dismiss the ethical concerns about negatively affecting male sexuality that apply to every male child circumcision. It implies that it’s acceptable to control male sexuality (i.e. permanently reduce it) to limit sexual activity during teen years. It implies that males may inherently be incapable of controlling their own sexual behavior. There’s also the possibility that her implications are targeted only at the poor, the subject of this bill to restore Medicaid funding for non-therapeutic circumcision. I suspect her concern is for the general application of circumcision upon males, not just poor males covered by Medicaid. Regardless, Rep. Schafer’s question exposes the issue and its connection to unquestioned parental proxy consent for male circumcision, a permanent, non-therapeutic surgical intervention.

It’s useful to have this clear example because it’s a common misconception that male circumcision of minors involves no control or attempted control over male sexuality. That’s a misconception because non-therapeutic male child circumcision is always control. The patient receives only someone else’s idea of what a “normal” penis should be. He can no longer exercise control over his normal, healthy body, only his altered body. The flaw is most commonly some form of drivel about the preferences of the boy’s future sexual partners, which is speculation, but it applies to religious justifications, as well. Someone else imposes what the child “should” want. The truth is clear: all non-therapeutic child genital cutting controls sexuality.

The challenge to defeating the common misconception rests on separating parental intent from the act. The accepted argument entails the idea that male genital cutting can’t be something bad because the parents have good intentions. American parents think they’re doing what’s in the best interests of their sons, so we’re told we must accept that this negates the obvious reality of what the act is and does. That’s flawed because the act matters before we consider intent. Parents do not intend harm, but circumcision (i.e. surgery) causes harm. We can – and must – make a judgment on the act without regard to intent because it’s a non-therapeutic intervention on a non-consenting individual. It fails ethics.

Lawsuits as Strategy

I resisted commenting on this story. I don’t think it’s worth our time as activists for several reasons. One, the petitioner, Dean Cochrun, is an inmate in prison for kidnapping. He’s not exactly a sympathetic individual, even though I agree with the gist of his claim. Two, He’s representing himself. He’s going to make a mess of this, on the off chance it proceeds beyond his initial filing. I read his self-written complaint to judge it. I’m not an attorney so I’m not sufficiently qualified in much of the debate. Still, it’s clear how unfocused and emotional his claim is, when there’s a legitimate approach based on objective facts about circumcision and the unethical disparate treatment of healthy boys and girls. We can do better.

There are some relevant topics to discuss, though, which are brought out in this report by Stephanie Rabiner, Esq. at FindLaw. (Again, the caveat applies that I’m addressing these concerns from a layman’s perspective.)

Can circumcision rob you of your, uh, “sexual prowess”?

A South Dakota man thinks so, which is why he has filed a federal circumcision lawsuit against the hospital where he was born. He claims he only recently learned of his missing foreskin, and that doctors misled his mother into believing the procedure was medically necessary.

This is a fair reading of the complaint, but I don’t think it’s complete to say the he claims doctors misled only his mother. Mr. Cochrun wrote “Unknown Doctor who performed this procedure had misled my mother by failing to inform her that there are no medically necessary reasons for performing this procedure and so by the Unknown Doctors acts or omissions I was permanently and irreversibly scarred and deformed.” In the next two sentences he wrote: “By doing so the Unknown Doctor infringed upon the rights of my mother, father, and self. My mother and father were unable to make an informed decision because they were not provided with the facts necessary.” He references both his parents. This speaks to my claim that his suit is unfocused and poorly structured.

His argument is also problematic because it implies that parents have a right to impose non-therapeutic genital cutting if they’re sufficiently informed. They don’t, partly because they can’t be. The only rights involved in non-therapeutic genital cutting, those that were violated, belong to Mr. Cochrun. That should be the approach for any lawsuit, even if arguing that parents are insufficiently informed of the harms and risks of circumcision is a path to the inevitable, eventual recognition of genital integrity for all children.

Ms. Rabiner’s analysis continues, after a bit of laughing because of his name (an immature aside suggesting she hasn’t quite applied a sufficient openness to the general claims represented within Mr. Cochrun’s suit):

Cochrun, 28, is currently in prison on a kidnapping conviction, according to the Associated Press. This may explain why he had both the time to file such a strange lawsuit and why he only recently became aware that he was lacking in the foreskin department.

Unnerved by this revelation, he now claims he “was robbed of sensitivity during sexual intercourse.” The circumcision lawsuit further states that he lost “the sense of security and well-being I am entitled to in my person.”

Whether or not Mr. Cochrun is truthful in his claim, I do not find it difficult to believe that someone would not know he is circumcised (or intact). It’s common, as demonstrated in studies and anecdotal reports. Culture is weird in many ways. Dismissing such a revelation because it contradicts an assumption suggests we should check the assumption.

But, to the analysis within her post (link in original):

This is all well and good — and a little sad, to be honest — but it’s almost certain that a judge will toss Dean Cochrun’s suit. Here’s why:

  1. Consent. Cochrun was an infant when he was snipped, which means his mother had the legal right to consent to the procedure. There’s no indication that doctors lied to her.
  2. Statute of limitations. Personal injury lawsuits can’t be filed 28 years after the events in question. Sure, some states may toll – or pause – the clock and only restart it when the victim first learns of the injury. But it’s highly unlikely Cochrun didn’t know he was circumcised.
  3. Lack of jurisdiction. Cochrun lives in South Dakota. The hospital he is suing is in South Dakota. He has filed a state law tort claim. He filed his circumcision lawsuit in federal court. Federal courts have no jurisdiction to hear his claim.
As to this third point, even if Dean Cochrun re-filed his circumcision lawsuit in state court, the first two points will still apply. His lawsuit will undoubtedly be cut short.

In reverse order… The last point is the key here, which I didn’t process on my first reading. (Give me an ‘F’ in Civil Procedure, I suppose.) But, yes, that’s the best defense of my request not to get behind this suit or make too much of it. But even if he refiled in a state court, my opinion doesn’t change.

On the second point, from the included link:

… A child or a person with a mental illness is regarded as being incapable of initiating a legal action on her own behalf. Therefore, the time limit will be tolled until some fixed time after the disability has been removed. For example, once a child reaches the age of majority, the counting of time will be resumed. …

If this South Dakota code is what would apply in state court and I read it correctly¹, the clock began on Mr. Cochrun’s 18th birthday and ran out on his 19th birthday. Arguing that this suit is faulty because he filed 28 years after his circumcision seems to be incorrect. It should be that he filed 9 years too late. For purposes here, I’m granting that Mr. Cochrun’s “[m]ere ignorance of the existence of a cause of action” did not toll the statute of limitations because “the facts could have been learned by inquiry or diligence”, even though I’ve already demonstrated that it’s possible he may not have known his circumcision status until recently. Whether or not it’s true, it could be. It deserves serious consideration, even if it doesn’t change the conclusion on Mr. Cochrun’s claim.

Speaking of what deserves serious consideration, the correct consent argument relevant to non-therapeutic child circumcision is not presented in Ms. Rabiner’s analysis. I have no doubt that she’s correct that the consent involved rests on legal rather than right. It’s also probably nuanced and complicated with a long history in the common law. But that’s what needs to change. It already has with respect to female minors, so the notion that parents have a right to surgically alter (i.e. harm) a healthy child, but only a male child, is odd and needs to be relegated to the past as a relic of flawed, inexcusable human thinking. If it’s a right, it’s a right against all healthy children, not just male children. Any continued defense of a discriminatory distinction as a parental right is a problematic continuation of our shallow, uncritical thinking on the harm of circumcision. Non-therapeutic genital cutting on a non-consenting individual is either wrong or it’s not.

The best way to achieve full protection of genital integrity and bodily autonomy is through cultural change. It’ll be the most likely to last. But that’s slow, and real individuals have their rights violated while that change develops. Thus, other methods are valid to achieve the same result. Next best is to have elected officials extend the protection we provide to everyone but male minors to male minors, as well. Given how likely that is(n’t), other options are necessary. Which leaves us with lawsuits. The courts are (hopefully) an impartial place to work out these issues to respect the rights of all individuals. Punishing those who violate the rights (and bodies) of children, even if punishment occurs only in civil court, will circle back as an incentive on cultural change. The idea of Mr. Cochrun’s lawsuit is spot on, even where it’s execution is misguided and flawed.

¹ Any lawyers who may read this, please don’t be afraid to correct me on this.

Fact Sheet

The WHO fact sheet on FGM is excellent, for what it does. I’ve modified and condensed it below into a universal, concise fact sheet on genital mutilation that respects equal human rights for all (male, female, and intersex) individuals.

Genital Mutilation

Key facts

  • Genital mutilation (GM) includes procedures that intentionally alter or cause injury to the genital organs of a non-consenting individual for non-medical (i.e. non-therapeutic) reasons.
  • GM is a violation of human rights.

Genital mutilation (GM) comprises all procedures that involve partial or total removal of the external genitalia of a non-consenting individual, or other injury to the genital organs of a non-consenting individual for non-medical (i.e. non-therapeutic) reasons.

GM is recognized internationally as a violation of human rights. It reflects deep-rooted inequality, and constitutes an extreme form of discrimination against children. It is nearly always carried out on minors and is a violation of the rights of children. The practice also violates a person’s rights to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death.

Procedures

Genital mutilation is classified as:

  • Any surgical interventions or harmful procedures to the healthy genitalia of a non-consenting individual for non-medical (i.e. non-therapeutic) purposes

No therapeutic benefits, only harm

GM has no objective, immediate therapeutic health benefits, and it harms individuals in many ways. It involves removing and damaging healthy and normal genital tissue, and interferes with the natural functions of the individual’s body.

The Duty to Run Interference

Author John Scalzi posted an essay on his blog, Whatever, from an unnamed friend who is a doctor. It discusses the recent furor over the political push for transvaginal ultrasounds mandated for political “need” rather than medical usefulness. The essay is well-worth reading. I wish to post an excerpt relevant to my purpose for Choose Intact because it involves a doctor’s responsibilities in medical intervention. The doctor is concise, specific, and irrefutable. The logic is as applicable here as it is in non-therapeutic transvaginal ultrasounds.

It is our responsibility, as always, to protect our patients from things that would harm them. Therefore, as physicians, it is our duty to refuse to perform a medical procedure that is not medically indicated. Any medical procedure. Whatever the pseudo-justification.

It’s time for a little old-fashioned civil disobedience.

And from the doctor’s proposed step two to protect patients from such legislation:

Our position is to recommend medically-indicated tests and treatments that have a favorable benefit-to-harm ratio… and it is up to the patient to decide what she will and will not allow. Period. Politicians do not have any role in this process. NO ONE has a role in this process but the patient and her physician. If anyone tries to get in the way of that, it is our duty to run interference.

An excellent summation of the physician’s responsibility to his/her patient.

“Since not all men are willing to be circumcised,…” (Part 2)

Update (5/31/2012): To the extent appropriate, my update to Part 1 applies here. I have not edited anything in this post, though. [End Update]

Note: Here is Part 1 of this series rebutting the recent meta-analysis purporting to demonstrate that infancy is the best time to impose circumcision on healthy males.

The interesting thing about the Brian Morris, Jake Waskett, et al article, “A ‘Snip’ in time: what is the best age to circumcise?”, is how reckless they are with their logic. They toss out information without regard for obvious rebuttals or how unrelated the so-called evidence is to their conclusion. If they think it might stick, they include it. One can only conclude that they started with the outcome of their analysis before gathering the supporting data.

For example, in their conclusion, they write that early circumcision “means an assurance of greatly reduced risk of penile cancer later in life, no smegma, better hygiene, and lower risk of various STIs.” They don’t include anything on why smegma is supposedly bad and thus indicates circumcision is not only good, but should be imposed on healthy infants. I’m sure they can find something, although I doubt it would be compelling. There’s also the logical question of why it’s an indication for non-therapeutic genital cutting on boys but not girls, who also develop smegma.

They continue this effort in their conclusion. In a sub-heading they write:

Some of the arguments against waiting until later to circumcise are:

• The cost (to the individual or the public purse) is much higher, and often unaffordable, for later circumcision.

The cost to the individual who doesn’t need circumcision later in life is zero. That population would be very large for males left intact. Even from the irrelevant “public purse” approach, they would need to calculate the cost of therapeutic circumcision paid for by they public later in life against the cost of non-therapeutic neonatal circumcision (cost per instance X number of instances). They don’t.

Also, the time value of money must be factored into the comparison. A dollar spent today is not the same as a dollar spent twenty, thirty, or more years from today. The number of adult circumcisions needed would have to be even greater to justify their public purse argument. It still wouldn’t be ethical to circumcise healthy infants, of course.

That’s not the worst “argument against waiting” they offer. This is:

• Educational resources for boys to make an informed decision are quite limited.

I had to read this several times to be certain it said what I read. They can’t be this ridiculous. They are.

The immediate, obvious rejection of that nonsense is that boys (and adult males) can use the same educational resources Morris, Waskett, et al suggest parents use to make an “informed” decision. Surely they exist, or else the position that parents can make an informed decision without adequate educational resources is irresponsible. What makes the male himself too stupid to understand the same materials? There’s no defense for their statement or their conclusions.

They offer a few more:

• Boys who later choose circumcision will likely wish it had been circumcised in infancy.

This is the bizarre argument I’ve encountered from Waskett, the mythical “right” to grow up circumcised. But this is the radical position. Boys who would later reject circumcision can’t undo the harm imposed on them. The authors incorrectly dismiss this. It is the center of both the physical and ethical argument against non-therapeutic child circumcision.

• Many older boys and men may not want to face an operation even though they wish to be circumcised.

That ties to a statement earlier in their article:

Even if a man is willing to be circumcised this does not mean he will end up having the procedure done. On the other hand, a lack of willingness to be circumcised should not be interpreted as a preference to be uncircumcised. This is because a large number of obstacles have been documented, such as fear of pain or complications, embarrassment, inconvenience and cost. The obstacles are discussed in the following sections. It is reasonable to suppose that, if these barriers could be addressed through the provision of correct information and financial assistance, the fraction of men willing to be circumcised would increase significantly. Better education of parents before or soon after their baby is born about actual risks should, by helping to ensure a circumcision in infancy, avoid later deliberations and barriers to circumcision in adolescence and adulthood.

That’s very convenient for their preference. Just assume anything that helps your position and disregard anything the suggests something else. Notice the shift in that paragraph. The last sentence of that paragraph has zero relation to the rest of the paragraph. A male’s refusal to be circumcised despite a claimed desire to be circumcised demonstrates that he values avoiding the costs more than receiving the benefits. The only reasonable supposition is that the infant would likewise be unwilling to undergo circumcision if left his choice. The authors’ suggestion is nonsense.

There is at least one more installment to come.

What Applying the Science Says About Circumcision

It’s frustrating to read people writing about the science of non-therapeutic infant circumcision while omitting ethics and a full consideration of what constitutes harm. Such is the case with a series of posts at SquintMom. The blogger, Kirstin, is doing a series of three posts, “What the Science Says About Circumcision”. Part 1 on the benefits is here. Part 2 on the risks is here.

I have a lot to say on the two entries posted so far, but I’d rather organize my thoughts into identifying a more generalized flaw in the series. As I said, this is primarily the ethics of applying the science. Several times in Part 1, she uses parentheticals to explain the circumcised men in the studies. “With their permission”. “With their consent”. This matters. She concludes that there aren’t enough benefits to support routine circumcision in the U.S., which is the right conclusion. But her assumption seems to be that some level of benefit could justify routine infant circumcision. That’s too utilitarian. Individuals have different levels of risk aversion. A male’s willingness to accept risk may be greater than his parents’. We can’t know. Even if our HIV problem in the U.S. matched that of sub-Saharan Africa, I wouldn’t want to be circumcised. I’m responsible. I do not need circumcision to reduce my risk beyond the trivial risk I would face. No level of benefit could justify circumcising me without my permission and consent.

A willingness to carry “I don’t know” through its implications is the better conclusion for Part 2. That’s not what she offers. It’s incorrect to say “[i]t’s fine to make a decision based upon values”, as she did in her intro to Part 1. Circumcision causes physical harm, contrary to her conclusion. That she thinks that isn’t “significant”, a subjective word in the application of the science to healthy individuals, isn’t relevant to what we should allow parents to do to their – male, only¹ – children. What does the healthy male want? She mistakenly gives this no weight in her conclusion.

On the topic of harm, it’s worth starting on the legal point. Legally, all surgery is battery. Circumcision is surgery. Therefore, circumcision is battery. It is physical harm. It removes the normal, healthy foreskin. It involves risks, however insignificant they may seem to anyone other than the patient. Someone will be the statistic. He matters, too. (Again, this omission is why utilitarianism is awful.) It leaves a scar in every case. There is objective, guaranteed physical harm. To conclude that there is no physical harm to every circumcised male rather than just those who experience complications, as she did, is factually incorrect.

The legal defense to surgery as battery is consent. But non-therapeutic infant circumcision involves proxy consent, which requires a different standard. The objective is least invasive procedure possible that preserves the patient’s choices to the greatest extent possible. Since there is no procedure indicated because the child is healthy, there is no decision to be made. Permitting non-therapeutic circumcision is unethical. To address SquintMom’s recent post, “Options, Ethics, and Moral Imperatives”, a society’s overarching social philosophy can be wrong. Here, it is because non-therapeutic (i.e. “routine”) child circumcision involves objective, permanent physical harm without objective benefit.

As an example of where SquintMom went astray, I think this is a solid example (emphasis in original):

While the foreskin has sensory function (Taylor et al), there is no scientific evidence to suggest that the loss of these receptors affects sexual satisfaction or the intensity of the sexual experience for men. One study even goes so far as to suggest that while there isn’t currently evidence to support the notion that circumcision somewhat desensitizes men, even if such evidence existed, it wouldn’t necessarily be a bad thing, given that more men (and their partners) complain of premature ejaculation than complain of inability to achieve orgasm (Burger et al). While Burger doesn’t go so far as to suggest circumcision to prevent problems with premature ejaculation, these observations do put into perspective the “intactivist” argument that circumcised men don’t enjoy sex as much as they otherwise would; clearly, for the vast majority of men, enjoying sex isn’t a problem. The scientific evidence does not support the notion that male circumcision diminishes sexual performance in men, nor sexual satisfaction in men or women.

First, note the utilitarianism again. The foreskin has sensory function, but no evidence suggests… More men complain of X than complain of Y. That doesn’t eliminate the possibility that a man will want that sensory function or the concern for Y and the individuals who experience that. (I do not assume it is a direct result of circumcision.) Apart from the obvious fact that the loss of that possibly irrelevant sensory function still constitutes harm, SquintMom’s statement implies that all men value everything in the same way, or that they “should” value X more than Y. That’s obviously false. I don’t like coffee. Therefore, you don’t like coffee. Valid?

Clearly, for the vast majority of men, enjoying sex isn’t a problem. Yep. So? The better response is to carry through the implications of “I don’t know”, since we can definitively say not all circumcised males will enjoy sex. Specifically, we need not go beyond the men who are the statistics, the ones who incur a complication that is severe. The number of males who lose their glans, their penis, or their life is small, but the number is not zero. Who is going to be that male? We don’t know. Permitting parents to cause harm by applying the science of “no scientific evidence of harm” to their healthy – male, only – children means there will be males who either don’t enjoy sex or don’t live to enjoy sex. Applying the science of “no scientific evidence of harm” also assumes we won’t find any evidence in the future. The truth is that we don’t know.

She mostly expresses this point (e.g. “untestable claim”), but it’s not complete. Even ignoring what I wrote above on harm, it’s not definitive from her case that there is no physical harm from male circumcision. There is the possibility we’ll know more. In proxy consent, it doesn’t make sense to then apply the science of today permanently to the healthy body of another person based on parental values.

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¹ In her first post, she prefaced the series with “[f]emale circumcision is a completely separate practice, occurring for the express purpose of destroying sexual function.” She is wrong on both positions. (She repeats the former in the comment section of Part 2.) Female genital mutilation is usually imposed with that purpose, but not always. Cultural behaviors are complex, as she points out in her series. Why should it be different on something we (rightfully) abhor? (c.f. Consider these three posts.)

Anyway, the comparison is non-therapeutic genital cutting on a non-consenting individual. It can’t be wrong for one gender but acceptable for the other. There is no parental right to cut sons. That’s a bizarre world in which males and females have unequal rights to their own bodies. There is either a parental right to cut the genitals of healthy children, or no such right to cut healthy children. We rightly call the removal of a healthy girl’s clitoral hood “mutilation”. There is no ethical, legal, or scientific distinction to avoid protecting the analogous healthy body part in males.

This is what the World Health Organization states on FGM. It consists of four types, including type 4:

Other: all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.

Surgical alteration of the normal human body is harm.

FGM has no health benefits, and it harms girls and women in many ways. It involves removing and damaging healthy and normal female genital tissue, and interferes with the natural functions of girls’ and women’s bodies.

Would WHO rebrand female genital mutilation to “female genital cutting” and declare it an acceptable parental choice if some health benefits were found? I find the possibility doubtful, at best. So why shouldn’t we also apply the basic logic of harm as “removing and damaging healthy and normal genital tissue, and interferes with the natural functions of bodies” to males? It’s okay to do this without their consent because of cultural values? That’s absurd.

“Since not all men are willing to be circumcised, …” (Part 1)

Update (5/31/2012): I modified the first paragraph to focus my jabs. I should not have been as broadly rude as I was. I have great contempt for Brian Morris, but he should’ve been the only target for that contempt. The other authors merely frustrate me via either personal interactions or their public statements. In my interactions with Mr. Waskett, specifically, I haven’t experienced the contemptible behavior so easily witnessed from Morris. I regret that mistake.

A long list of familiar names have conducted a meta-analysis of a bunch of studies involving circumcision. The article purports to ask the question “What is the best age to circumcise?”. (Notice the implicit assumption that a male should be circumcised.) They don’t address that question, of course, instead answering “How can we encourage infant circumcision?”. They only justify it in their minds because their analysis is lacking. I didn’t expect anything better after seeing Brian Morris attached to it. (Jake Waskett, Aaron Tobian, Ronald Gray, Robert Bailey, Daniel Halperin, and Thomas Wiswell, among others, are listed as co-authors.)

I’ll probably post more extensive critiques because it all deserves as public an airing as possible. Their credibility deserves to be attached to this awful piece of scholarship. For now, I want to focus on this, from the section titled “Is infancy the best time medically?”. It offers a succinct example of their incomplete, flawed approach.

All boys are born with phimosis. This resolves by about age 3 in all but approximately 10% of males, who as a result experience problems with micturition, ballooning of the foreskin, and painful difficulties with erections (see review [9]). Paraphimosis can similarly be prevented by infant MC.

This is silly. All boys are born with phimosis? That’s a stupid way to explain normal human development. They’re pathologizing the healthy infant foreskin to justify the conclusion they want to reach. How many of those boys in the 10% will have their foreskin naturally separate (i.e. “resolve”) after age 3 and will never need any intervention to achieve this? They’re implying that an intervention is necessary for healthy, intact three-year-old boys whose foreskin hasn’t fully separated. (The whole paper is that, except stated rather than implied.)

Throughout the paper, they never consider the important question when reaching the conclusion that something can be “prevented by infant MC”: how many legitimate instances of phimosis/paraphimosis/UTI/whatever require circumcision later in life because another, less invasive intervention is insufficient. They declare that the risk in intact males “of developing a condition requiring medical attention over their lifetime = 1 in 2”. (I’ll grant that because it doesn’t alter the conclusion on non-therapeutic infant circumcision.) They never identify how many of those require circumcision. Yet they use this 50% figure as a justification for infant circumcision. The need for circumcision rather than the need for medical intervention is what’s relevant. Their focus is mistaken and leads to their incorrect conclusion.

In the “Cosmetic Outcome” section, they write:

When circumcision is performed in infancy the ability of the inner and outer foreskin layers to adhere to each other means sutures are rarely needed and the scar that results is virtually invisible [98]. Other factors include the more rapid healing at this time of life, contributed by age-associated differences in pro-inflammatory factors that might affect scar formation [145].

Once again they’re using normal human development to manipulate a path to their predetermined conclusion. They’re using a convenient aspect of the surgical procedure rather than medical need to justify imposing the surgical procedure.

The ability of an infant’s inner and outer foreskin layers to adhere to each other once cut also demonstrates that boys are not born with phimosis. This ability is evidence that the normal foreskin is not supposed to be separated from the rest of the penis at birth. Neither argument is a valid defense of infant circumcision, but the authors can’t have both in their attempt. Doing so is just a way of presenting the preferences they like as the only preferences worth considering. That’s biased by the authors’ utilitarianism. Remember when I wrote “[t]he utilitarian approach is subjective and has a tendency to favor whatever argument someone is making because it assumes all people favor the same choices”? Their article is a perfect example of that.

Since that ability is classified under “cosmetic outcome”, let’s discuss that. My circumcision healed the way they suggest. The scar did not heal “virtually invisible” for me. Any cursory review of pictures of circumcised penises will show that the scar is almost always quite visible. My complexion is very light, so I suspect my scar is less visible than what most males experience. But it’s still quite visible. They’re wrong. This error is inexcusable.

Perhaps the cosmetic outcomes of circumcision, infant or adult, are desirable to Morris, Waskett, et al. They’re entitled to their opinions about their own bodies. It does not follow that parents who share that preference may force those onto the body of a child – male only – who may not share that preference. The cosmetic outcome of circumcision is hideously ugly to me. I wouldn’t choose it for myself if I still had my choice. I am not the only one, since not all men are willing to be circumcised. The author’s opinion or statistics on female preferences about a male’s normal body are irrelevant until and unless the individual decides he wants himself circumcised.

Unsurprisingly, the authors never discuss male preference in the Ethics section. (More on that later.) The title of this post is the closest they get to mentioning the possibility. They mistakenly use that sentiment to reach the conclusion that infants should be circumcised. They endorse the view that if you can’t convince someone, promoting its imposition on them is somehow defensible. It isn’t.

Universal Excuses for Genital Cutting

The AAP’s policy on female genital mutilation offers an interesting comparison to the defense Rabbi Shmuly Yanklowitz attempted for the “moral” case in favor of circumcision. The AAP’s policy contains this within the “Cultural and Ethical Issues” section:

Kopelman has summarized four additional reasons proposed to explain the custom of FGM: 1) to preserve group identity; 2) to help maintain cleanliness and health; 3) to preserve virginity and family honor and prevent immorality; and 4) to further marriage goals, including enhancement of sexual pleasure for men. Preservation of cultural identity has been noted by Toubia to be of particular importance for groups who have previously faced colonialism and for immigrants threatened by a dominant culture. FGM is endemic in poor societies where marriage is essential to the social and economic security for women. FGM becomes a physical sign of a woman’s marriageability, with social control exercised over her sexual pleasure by clitorectomy and over reproduction by infibulation.

The italicized theories are quite similar to the justifications Rabbi Yanklowitz proposed. But there’s more:

When parents request a ritual genital procedure for their daughter, they believe that it will promote their daughter’s integration into their culture, protect her virginity, and thereby guarantee her desirability as a marriage partner. Parents are often unaware of the harmful physical consequences of the custom, because the complications of FGM are attributed to other causes and rarely discussed outside of the family. Furthermore, parents may feel obligated to request the procedure because they believe their religion requires female genital alteration.

The alleged moral and ethical distinction between female and male genital cutting is a fantasy. They are the same violation, often for the same reasons. There is no defense for permitting tradition and potential medical benefits to excuse this violation for one gender. It’s all non-therapeutic genital cutting on a non-consenting individual.