Category: Ethics

Further Thoughts on Dr. Diekema’s Recent Statements

Now that I’ve rebutted the possibility of a revised AAP position that more favorably supports non-therapeutic infant circumcision, I want to comment on a few additional statements from the interview with Dr. Doug Diekema.

Diekema is aware that there is a movement of “intactivists,” or people who believe that it’s wrong to cut off part of a baby’s body if not medically necessary. “I get huge mailings with FedEx boxes, summaries. I do look at it — I have a file of all of that — but I am not about to let them do the evaluation for me.”

I agree, he shouldn’t substitute anyone’s evaluation for his own. But he should evaluate everything, including the implications of a policy to the individual he acknowledges who might not want that policy applied to his body, permanently. Merely citing the ethical conundrum without drawing a conclusion in favor of the patient, or drawing a conclusion that some possible benefit preferred by someone else for a minor risk justifies setting aside a basic bodily right everyone possesses, is unacceptable.

Diekema said that “hundreds of papers were reviewed and judged for their quality” and that people from the anticircumcision camp “will quote you all kinds of studies — which were frequently terrible and didn’t prove anything because they were so methodologically flawed.”

This is a problem. We should all strive to be logical and accurate. That’s why I don’t cite certain sources and statistics seemingly in favor of my position.

On the other side, it’s also problematic to quote the statistics derived from voluntary, adult circumcision in Africa and apply them to forced circumcision of healthy infants in America. The HIV epidemic is fundamentally different in the two populations. And citing the impressive relative risk reductions without honestly dealing with the unimpressive absolute risk rates and reductions is flawed, as well. This also ignores whether or not the male would prefer an increased risk of HIV transmission from his female partner(s) in high-risk populations. Dr. Diekema acknowledged that not all men would make this trade.

“They don’t like what we’re doing. I get hate mail from them all the time, trying to paint what we’re doing as pro-circumcision. I am conflicted about circumcision personally. It’s a hard choice; it’s a hard decision, and there are good reasons for almost any decision you want to make.” He described his task force as “a moderate group — not pro, not anti. We’re trying to uncover what’s real here.”

It’s not a hard choice. There aren’t good reasons. What’s real here is that the child is healthy. No surgery is indicated. That’s a basic point that should be easily understood and universally applied. That’s the entire discussion. The AAP should declare that non-therapeutic child circumcision should cease immediately.

He said that circumcision removes “maybe 1/3” of the skin on a male’s penis but said that may or may not affect sexual experience. “What you really want to know — ,” he says, “it’s fine and dandy to say circumcision removes all kinds of nerve cells, but more nerves doesn’t necessarily equate to more pleasure — so what you really want to know but can’t look under a microscope and get the answer is: How has the sexual experience changed?”

Ultimately, “we don’t have any good data. Circumcised men may experience sex differently than uncircumcised men — intuitively that makes sense — but it’s simply not the case that we have an epidemic of uncircumcised men that don’t get pleasure or can’t function sexually.” When some men who were circumcised as adults in Africa were asked about the change in sexual function, Diekema says, “most men reported no difference — a small percentage report that it’s worse, and a small percentage report that it’s better. There’s such a psychological component.”

Of course it may or may not affect sexual experience. Human sexuality is complicated, with as many preferences for experiences as there are people. That alone should be enough. The males who would prefer to have their foreskin for its sexual purposes have their preferences superseded by their parents’ preferences. That’s not ethical.

But we already have the answer to a simpler question, whether or not the sexual experience changes. There was a foreskin before circumcision. There isn’t a foreskin after circumcision. That alters the sexual experience. Whether or not that is good or bad is a decision for the male affected, not his parents. The exclusive input on the psychological component is the male who owns the foreskin, not his parents. It doesn’t matter what they think about how circumcision affects – or should affect – his experience. Dr. Diekema said it himself. Not everyone would trade their foreskin. There is only one valid position on this topic.

Quoting Dr. Doug Diekema Against the AAP’s Position

There’s been some mystery about why the AAP has taken so long to issue its revised statement on routine infant circumcision. It was expected years ago but still hasn’t been released. I won’t speculate on why this delay continues. Instead, we must look at the only new piece of information, a bit of insider speculation revealed this week. Deirdra Funcheon interviewed task force member Dr. Doug Diekema for the Broward Palm Beach New Times.

“Your frustration is shared by many,” Diekema said. He said that it had been hard to coordinate schedules of the busy task force members but that they had finally completed an exhaustive review of all relevant studies, and now “our work is 95 percent done. To my knowledge, the [new] statement and technical report have been drafted and are being reviewed by other members of the task force. We expect that this will be released sometime this spring.” Said Diekema: “Our starting point was the existing policy statement from 1995, which took a fairly neutral stance — it said there were modest medical benefits and some risks. Since then, data has been generated that might alter that recommendation. It’s fair to say that there are much more clear medical benefits than there were at the time of the last report, although no radical change in the data regarding risk. I expect that the academy will come out with a somewhat stronger statement.”

I don’t think “somewhat stronger” suggests a statement that will say anything close to “everyone should circumcise their sons”. That’s a guess, but if the task force was determined to say that because they feared parents leaving their sons intact was any real danger to the boys, they’d work harder to coordinate their schedules. They didn’t. Still, any inching toward a more positive statement would be indefensible, because the statement should be stampeding to the ethical position, the one which removes the choice from parents and leaves the choice with its proper owner, the (healthy) child. But I suspect Dr. Diekema’s statement is less than we fear. As always we should respond to this with logic and respect. The facts are on our side.

For example:

He went on to say, “If you talk to reasonable people about what the data shows… it’s real. …

I’m interrupting his thought here to point out that “reasonable people” is a framing device intended to show that he’s serious, unlike others who reject the data. It’s pointless. Reasonable people can disagree on the data, the methodology, and the application without being insincere or propagandists.

On that point, the data also shows that almost every male has healthy genitalia at birth. No surgery is indicated. The pursuit of some possible future benefit is speculative because the child is healthy. This is as true for the normal foreskin as it is for every other body part on boys and every body part on girls. This is the ethical question improperly ignored when advocates ask us to focus on “what the data shows”. A healthy body is also science.

… [Circumcision] does carry some risk and does involve the loss of the foreskin, which some men are angry about. But it does have medical benefit. Not everyone would trade that foreskin for that medical benefit. Parents ought to be the decisionmakers here. They should be fully informed.

There’s the ethical question improperly ignored. Dr. Diekema understands that not all males would trade that foreskin for the medical benefit. The condition he set can’t be met. Parents can’t know if their healthy son will be one of those males. They can never be fully informed. This is the beginning and end of the discussion.

Dr. Diekema is a pediatric bioethicist. If he is to adhere to the ethics his position requires, he would immediately and completely oppose any AAP statement other than a complete rejection of non-therapeutic male child circumcision. Non-therapeutic genital cutting on a non-consenting individual who may not want the surgical alteration is ethically wrong.

Consider the AAP’s policy on the ethics of female genital mutilation (while remembering the comparison is non-therapeutic genital cutting on a non-consenting individual):

The physical burdens and potential psychological harms associated with FGM violate the principle of nonmaleficence, a commitment to avoid doing harm, and disrupt the accepted norms inherent in the patient-physician relationship, such as trust and the promotion of good health. More recently, FGM has been characterized as a practice that violates the right of infants and children to good health and well-being, part of a universal standard of basic human rights.

Which parts of the emphasized sections have an exemption based on gender? It’s certainly not the pursuit of benefits that he stressed in the linked interview. Those are subjective and speculative. He has indirectly testified to this standard in court. Participating in the revision of a statement to encourage parents and physicians to behave unethically doesn’t make sense.

An Example Disproves the “Moral Case for Circumcision”

Flimmaker Eli Ungar-Sargon (Cut) has an excellent post on Rabbi Smuly Yanklowitz’s flawed essay I wrote about earlier this week. He rejects Rabbi Yanklowitz’s arguments for many of the same reasons I did. Read it because it’s worth your time, as Eli’s thinking always is. Here I want to excerpt part of the background and context Eli provides. It’s important.

In the interests of full disclosure, Rabbi Yanklowitz is a member of one of the Jewish communities that I belong to here in Los Angeles and I have a cordial relationship with him. He is the founder of Uri L’Tzedek, a wonderful Jewish group that is devoted to social justice issues. This is remarkable in so far as Orthodox Jews have historically not been as involved with social justice as Jews from the more Liberal movements are. Rabbi Yanklowitz’s commitment to both Orthodoxy and progressive causes makes him something of a rare bird, which demonstrates a moral courage and awareness that few Orthodox Rabbis can manage. And yet, here he is trying to defend the indefensible.

Yanklowitz begins his article by declaring that he is someone who believes that mitzvot, religious commandments, have an ethical foundation. Taken literally, this statement is obviously false. There are a number of commandments that historically required Jews to commit acts of genocide and there are many other ethical problems with the structure of Jewish law (the status of women comes to mind as an obvious example). But the rabbi should not be taken literally here. What he means by this statement is two things. First, that he is not a fundamentalist, because he believes that human agency is a necessary part of religious interpretation and practice. Second, in his personal hermeneutics, ethics play an important role in shaping religious interpretation and practice. The rub, of course, is how one deals with situations in which morality conflicts with the Jewish tradition. Circumcision is an apparent, and I argue actual, instance of such a conflict. Yanklowitz seems to be trying to argue here that circumcision is not such an instance. …

**********

Related to Rabbi Yanklowitz’s essay, I found a quote I’d like to highlight. In a Q&A with Soraya Mire, a human rights activist and survivor of female genital mutilation, she states:

[Q.] Your father, a general under the military dictator and former Somali president Mohamed Siad Barre, objected to FGM. Why do you think your mother insisted the mutilation be performed?

A. Not only did Father witness the suffering of my sisters but he understood the backward cultural mindset and conformity in the face of violating a child’s bodily integrity. The institution of marriage is the focal point for mothers, and FGM allows them to prepare their daughters’ future security. In my case, Mother was so worried about securing my worth and marriageability that she didn’t consider the unbearable pain she was inflicting on me. FGM is physically and psychologically traumatic to any child and, yet, we have surviving mothers, like my own, who refuse to acknowledge this cultural torture, let alone feel or address their own pain. They became branded lambs with sutured lips as they watched our bodies ripped open like curtains. They had no power to stop the actions of those cruel hands or condemn the violation of our human rights. To them, this reckless ritual, called a “rite of passage,” was justified because the tradition must continue in order to preserve our virginity and, therefore, the family honor. It’s time to address the damage that is done to millions of women, along with the violation of their basic human rights. The atrocity must stop and we must do whatever it takes to bring an end to this ancient genital mutilation.

Compare that to Rabbi Yanklowitz’s argument on “Parental Values and Social Acceptance” (i.e. cultural conformity):

… Not circumcising a Jewish boy may hinder his social acceptance and his chances of finding a Jewish spouse. The overwhelming majority of Jewish women look for a mate who is circumcised. It would be cruel to prevent a man from potentially finding a suitable mate. …

As I wrote, this is a claim commonly made in defense of female genital cutting. In Ms. Mire’s answer we have the same scenario presented by Rabbi Yanklowitz, with only the gender changed. There is no compelling reason why this defense is acceptable for male genital cutting. Gender is irrelevant in the ethical/moral case against non-therapeutic genital cutting on non-consenting individuals.

“Moral Case for Circumcision” Ignores Morality

In this essay Rabbi Shmuly Yanklowitz attempts to make the moral case for infant circumcision. Rabbi Yanklowitz fails in every all seven attempts, and in the familiar ways. This is not surprising since non-therapeutic genital cutting on a non-consenting individual is immoral.

He starts with health. He makes the mistake of focusing on relative risk without concern for absolute risk or the implications of his approach. He concludes the paragraph with this:

… Is it fair to avoid giving a boy protection when it is available? It’s not only Jewish law to maintain one’s health but also Jews should serve as a model for this important health practice.

“To avoid giving a boy protection” is a weird way to frame this point. It shows the flaw because it suggests that the conclusion informs the defense rather than the reverse. It assumes parents are unreasonable if they don’t circumcise healthy boys. Is it fair to avoid giving any child any protection that might reduce the risk of something, regardless of how small that risk?

This approach to healthy children is only applied to the male foreskin. Every other possible intervention is rejected. We are not immoral when we “avoid giving” other potential protections. The moral case against infant circumcision demands its rejection as we already refuse to consider any other intervention that might reduce something at some point. Rejecting infant circumcision is the only consistent moral approach.

Next, explaining circumcision’s role in “sexual morality”, he quotes Maimonides and responds:

… Circumcised men may not have less sexual desire or more self control but teaching a value of sexual moderation may be one pedagogical goal of this ancient ritual. We have many sexual wrongs in society to be reminded of such as rape, adultery, impropriety, and molestation. Perhaps circumcision can serve as a sacred reminder for men, in our over-sexualized world, to cultivate self control.

What is this, if not a means to control male sexuality? I’ve written before about the mistaken belief that non-therapeutic male child circumcision does not involve control. It does, even if this is not consciously understood when expressing intent. So it is again with Rabbi Yanklowitz’s reasoning.

Worse, this is borderline insulting because he seems to imply that men are less likely to control themselves without some external intervention against their genitalia. If my foreskin hadn’t been removed shortly after birth, would I now be inclined to commit rape, adultery, impropriety, and molestation?

Next, Rabbi Yanklowitz offers a utilitarian approach:

If an uncircumcised man chooses to have the procedure done later in life, it will be much more painful (even with anesthesia) and dangerous than it would be for a newborn. It is the responsibility of parents to shield their children from unnecessary pain.

There is no guarantee a male left with his foreskin and choice will need or want circumcision later in life. Statistics show neither is likely. Yet, pain is guaranteed when a child is circumcised. The choice that shields the most children from unnecessary pain is to leave everyone intact until need arises or they can make the choice themselves. Instead of every child – male only – experiencing pain, only those who have the misfortune to have a malady or who decide that the potential benefits outweigh the costs (e.g. pain) for them will experience pain. From a utilitarian standpoint, the prudent (i.e. moral) position is to leave children intact with their normal genitals because this non-action causes the least amount of unnecessary pain.

It’s also questionable whether or not circumcision later in life is more painful and dangerous. If it’s more dangerous¹, the individual facing the danger can consent or reject the surgery if he doesn’t want the risk. (My assumption there is for elective, non-therapeutic circumcision, which is the issue involving infants.) And infant circumcision has its own dangers, since the foreskin is fused to the glans and it’s difficult to judge how much to take off since the child still has all of his growing remaining. Severe consequences like amputation and death can – and do – occur, as well.

The utilitarian approach is subjective and has a tendency to favor whatever argument someone is making because it assumes all people favor the same choices. Yet, each person must provide his own weighting to the relevant issues. (The typical flaw of utilitarianism is to completely ignore the value of the foreskin in the equation. Its loss somehow isn’t a cost of the surgery.) The utilitarian push for circumcision ignores that individuals are must live with the negative outcomes and/or the intended outcomes he may not want. All children together won’t share the lost glans, lost penis, or lost life in the instances of severe complications. It makes no sense to consider all children lumped together.

His fourth point is parental values and social acceptance. The topic itself demonstrates the necessary proof that this is about control. That control makes it immoral. The circumcision is unnecessary, yet the values of the parents override the child’s lack of need and possible preferences throughout his life. Making sure that others accept him via surgery elevates the opinion of others above his own about his body. It denies personal autonomy. The paragraph endorses that view, but these sentences warrant focus:

… Not circumcising a Jewish boy may hinder his social acceptance and his chances of finding a Jewish spouse. The overwhelming majority of Jewish women look for a mate who is circumcised. It would be cruel to prevent a man from potentially finding a suitable mate. …

This is a claim commonly made in defense of female genital cutting. If we reverse the genders in his position, it’s easily understandable that this is about controlling the child. There is no compelling reason why this defense is acceptable for male genital cutting while being (rightly) rejected for female genital cutting. It is immoral when imposed on either gender.

Next, he extols the virtues of modesty. I don’t have much to say on this. Parents surgically altering their son to remind him to live up to their idea of modesty is self-evidently about control, and thus, immoral.

Next, “unconscious memory”:

…We give our baby boys one token formative experience, and then we do all we can to protect and shelter the child. This experience helps to ensure that the boy can be a moral agent. However, this reasoning, of course, should not be extended beyond this minor example.

Whether this experience is “token” or not must be decided by the individual receiving it, not the individual giving it. It is a subjective judgment.

Beyond that, empathy is a wonderful trait. There are better ways to instill this in children involving parenting rather than surgery. Are males not empathetic enough, or capable of learning through logic and example, that they require such an experience before they can practice it in their lives? This is preposterous and impossible to prove. Using it as a defense isn’t acceptable, as evidenced by the qualifications offered at the end of the paragraph. Again, they suggest that the conclusion informed the defense rather than the reverse. (Every defense of circumcision suggests this in some way.) Inflicting pain and the removal of healthy body parts to teach lessons is immoral.

The last item is that circumcision is a symbolic reminder. It focuses on religion, which I’m going to leave alone. My response is that symbolism isn’t valid if the individual doesn’t value the symbols. There seems to be a considerable chance that a child will value many of the same things his parents value. I accept that without reservations. But the focus must be on the individual. This is not guaranteed for any individual. Permanently altering a child to remind him of something he may one day reject is problematic, at best.

Rabbi Yanklowitz proved nothing he set out to prove. The moral case for infant circumcision he attempted is little more than the most common responses given. The emphasis is on the parents, not the child. The moral case for surgery with children starts and ends with their physical need. For circumcision, there is no need. There is no moral case for non-therapeutic infant circumcision.

¹ This is where I’ll invoke the articles on the PrePex as an example. My objection to the recent pieces about it centers on the poor journalism rather than the device. I expect the device will eventually be tweaked to allow for infant circumcision at some point. That would be wrong. For now it’s a device for voluntary, adult circumcision. I have no objection to that. The claimed risks involved with the device are low. The claim that adult circumcision is more dangerous than infant circumcision doesn’t appear to hold up, generally, regardless of the method. This claim is a framing device of dubious quality rather than a fact to be negate ethics.

Small Victories: The New York Times Revises

The New York Times revised its article on the PrePex circumcision device. I have no way of knowing if that change occurred because of my entry on the subject or some other source that provided some revelation to the paper’s editors. Frankly, I don’t much care who got it done. The key is that the Times changed the article to inch closer to reality. It’s not close to perfect, but compare the two. The original:

Dr. Reed said he had heard that another device, Ali’s Klamp, was being tested in Kenya under protocols that seemed to match W.H.O. requirements. According to Circlist.com, a circumcision information Web site, it is a Turkish device dating to 2007, and works on principles similar to those of the Tara Klamp and another device, the SmartKlamp, approved by the F.D.A. in 2004.

The current, revised version:

Dr. Reed said he had heard that another device, Ali’s Klamp, was being tested in Kenya under protocols that seemed to match W.H.O. requirements. According to Circlist.com, a Web site with information about circumcision and arguments favoring it, Ali’s Klamp is a Turkish device dating to 2007, and works on principles similar to those of the Tara Klamp and another device, the SmartKlamp, approved by the F.D.A. in 2004.

This is an improvement.

Now that I’ve stated that, it’s a bit silly for the revision to declare Circlist a site that contains “arguments favoring” circumcision. Circlist is a fetish site. It hosts slash fiction fantasies, pornography, and pro-female genital cutting material, among its offensive content. It pushes unprincipled half-truths and distortions, with strategic omissions, designed to make circumcision seem fantastic and without any ethical flaws or harms, real or potential. The site’s treatment of non-therapeutic child genital cutting is on par with “Teach the Controversy“. It’s propaganda unbounded by facts. The New York Times still needs to ask itself the relevant question: How reliable is Circlist’s “information about circumcision” given the ridiculous nature of its “arguments favoring it”?

Thus, the victory, such that it is, feels hollow. The paper version can’t be revised. The online version still cites the website. It needs further revision, which would hopefully lead to more accurate, ethical coverage of circumcision and its implications for healthy children.

However, that revision is something. Whatever inspired this update, it’s a small sign of progress. We need more of these.

The New York Times Links to a Fetish Site

Update: It’s been pointed out that the link within the New York Times story is broken. It’s missing the “www” from the link, an understandable mistake. So, the paper linked incorrectly to Circlist. The proper conclusion is that the editors failed to fact-check in addition to not checking source credibility rather than the pathetic implication that they didn’t link to a fetish site. I missed this because I started at Internet Archive and worked backwards.

I’ve noted it throughout, but almost every link after the first paragraph of this post is NSFW.

Last month the Washington Post ran a commercial masquerading as an editorial. Today, the New York Times follows suit, but ups the offensiveness in an unexpected – and unacceptable – manner. The article is another regurgitation for the PrePex device, so I won’t quote any of the related nonsense. The largest problem is at the end of the advertisement.

Dr. [Jason] Reed said he had heard that another device, Ali’s Klamp, was being tested in Kenya under protocols that seemed to match W.H.O. requirements. According to Circlist.com, a circumcision information Web site, it is a Turkish device dating to 2007, and works on principles similar to those of the Tara KLamp and another device, the SmartKlamp, approved by the F.D.A. in 2004.

I removed the hyperlink from the excerpt because – unlike the New York Times – I refuse to link to a pro-circumcision fetish site. But it is instructive. It demonstrates how uninterested the New York Times is in logic and ethics. The story doesn’t seem to rely on Circlist for any specific facts since, again, this piece is merely a commercial. That doesn’t make the site’s inclusion in the commercial, with a direct link in the online version, any less problematic.

With any effort, a “journalist” like Donald G. McNeil, Jr. could presumably uncover the bias of Circlist. For example, from its “Considering Circumcision” page, this Editorial Comment:

It used to be the case that the argument between the pro-circumcision and anti-circumcision lobby groups was an argument of opinion versus opinion. That is no longer the case. The pro-circ groups (CIRCLIST included) now have proven scientific fact on their side, whereas the anti-circ groups continue to rely on a less tangible line of reasoning based primarily on the morality of genital integrity – especially as regards child circumcisions. Of necessity they have, in the main, quietly dropped their assertions that the science is bunk.

The reasonable response a journalist might have is to ask what part the health of the child at the time of circumcision indicates. Whether or not the science is valid or bunk is secondary. The application of that science to a healthy (also science) child’s genitals is the ethical/moral question. In the analysis, ethics > science.

In other locations, Circlist believe[s/d] that “Parental Request” is an indicator for circumcision. (And a tight foreskin, and a long foreskin, and a loose foreskin. As long as the end result is YAY CIRCUMCISION…) But, since the child is healthy, that informs the morality involved. Circlist is like most pro-circumcision propagandists. The potential benefits supposedly demonstrate that it is ethical, as opposed to being merely a piece of information. Because it can possibly impart something does not make it ethical. If it did, prophylactic surgery of any type on children would be ethical. That’s stupid.

Any length of time spent on Circlist would reveal the depth of its bias (and kink), which at the least requires some offsetting balance if it’s going to be a source for the New York Times. The challenge is in finding out what the members of Circlist believe. Sometimes, they tell you. On the site today:

FIANCÉE GIVES HUSBAND-TO-BE AN EROTIC CIRCUMCISION

The following text is a work of fiction written by an anonymous contributor living in North America. The story involves a Do-it-Yourself circumision. CIRCLIST recommends that you do not mimic the scenes described. Circumcision should only be carried out by a qualified medical practitioner.

There are more at the link I’m not providing. Advocates who’ve been involved in this topic for more than a few years are familiar with what else the site contains and/or contained. Contained is the key I want to focus on now. The current site has been scrubbed of some material, but the Internet Archive reveals its not-lost secrets. (Remaining links are from March 25, 2008, a date picked at random.) Such as more stories and pictures that are very much NSFW, although I don’t recommend the NSFW link. The subject is “Foreskin Has Erotic Purpose For Some”. That’s a way of saying there’s still a circumcision to be done that can generate sexual excitement, not that maybe the foreskin should stay.

Next, (NSFW):

As for infant circs, I am sure, since you are circ-obsessive or you wouldn’t belong to this club, you’ve seen your share of adults circumcised as babies. Many of their scars are quite extensive and, dare I say it, ugly. From the sulcus down to the shaft skin it’s bumpy, red and sometimes looks quite sore. Whether it is sore or not, I can’t say. Also, when the frenulum has been removed, the raw area left in the wake of the surgery can look quite angry. Some guys say that this is still their most sensitive area on their penises, as is mine, even though I instructed the doc to leave mine alone. The worst consequence of these infant circs without sutures is the skin bridge (see photo at right). Sometimes the inner foreskin edge doesn’t grow to join to the shaft skin edge. It turns back on itself and joins with the corona of the glans. From all accounts this bridge can be benign or very painful in sex.

Notice that they are happy to publish that they’re circ-obsessive at the same time they publish a clear explanation that circumcision causes problems. (The corresponding picture and others show circumcision fits the definition of mutilation, especially when forced on another.) Yet, they think the moral question of imposing this on healthy children is essentially a non-issue. Why would anyone trust them to be a good judge of ethics?

Finally, if you click to Circlist today, you’ll find a very different view of female genital cutting than in the past. More on that in a moment. But what’s interesting is how they currently differentiate between female genital cutting and female genital mutilation. They don’t think the distinction is what you think it is.

Female Circumcision (“Femcirc”): Surgery that modifies the female genitalia in ways likely to be accepted by a neutral observer as enhancing the quality of a woman’s sexual experience.

Female Genital Mutilation (“FGM”): Surgery that modifies the female genitalia in ways likely to be accepted by a neutral observer as reducing the quality of a woman’s sexual experience.

The consent of the female isn’t discussed. It’s merely whether a “neutral observer” thinks the cutting “enhances” the sexual experience. They are not endorsing a view that females have a right to their bodies, just that someone else’s perceived benefits to sexuality is a valid reason to cut. They discard the moral question of non-therapeutic male genital cutting, which is unsurprising. But they discard the moral question of non-therapeutic female genital cutting, as well, in spite of its clear position within the Western world. They’re not arbiters of ethics and human rights, yet they’re quoted in the New York Times. Why?

All of that is offensive, but their past interest was more involved. (NSFW) From “Cindy (USA)”:

I recently had my clitoral hood removed (female circumcision) to improve sensitivity and cleanliness as it was such a long hood. I had some pain during healing, but that has been minimal. Healing has been rapid.

The glans clitoris has slowly increased in size since the operation. The sensitivity is also there and my ability to orgasm has increased be cause of it.

I think that all women should consider have their hoods removed as it would aid in cleanliness of the area and grreatly improving orgasm! I’m totally satisfied!
…

Next:

Photos of my girlfriend Lisa, before and after her circumcision are attached. She previously had her clitty hood circumcised, and now her lips. I think she looks much better, don’t you?

Finally, from “French Couple Advocates Both Male and Female Circumcision”:

We are a French couple , 32 years old, from Metz, in the east of France. I am Pascale (wife), my husband is Marc. We have 3 children, 2 girls, one boy.

We are strongly interested in male AND female circumcision, especially female because male circumcision is not a problem for us. My husband has been circumcised (well circumcised) for 3 years.

Marc (my husband) has a very tight circumcision with the frenulum completely removed. It was done 3 years ago, voluntarily, and without any medical reason, only to be very clean and erotic (I write my opinion!) Marc is very happy.

Mathieu (my son) also has a very tight circumcision, frenulum completely removed. We had him circumcised completely at birth. He is now 3 years old and his circumcision looks very good.

Unhappily I am not not yet circumcised, but I WANT it. We are searching information, testimonies, addresses for my female circumcision. I think that female circumcision is analogous to male circumcision and is also necessary to the couple’s sex live. I think it should be better to allow female circumcision . I am now speaking about cutting the hood and the labia minora. I am also searching for information about the complete cutting of the clitoris.

When I was 19 y o, I had a (girl) friend that told to me that she was cut off like an African woman: She had lived in UpperVolta (now Burkina Faso), with her parents, and her mother thought it was a good practice to be cut: All the females of the family were cut in a local hospital by a nurse. She had no regrets and was not ashamed to be a White French Excised woman. She showed me the result of the operation. I thought I would like to be like her.

Last years in Cap d’Agde, a huge naturist town in the south of France , we saw a couple of smooth circumcised Dutch: They had no pubic hair (like us), and the wife had her nipples pierced with rings. Also her clitoris was pierced and had no hood and was ever protruding. She had no labia minora. I want absolutely to be cut and pierced like her.

Circlist is a fetish site. It’s present is tamer than its past, but the underpinning is still there. Yet, today they’re being quoted by the New York Times. The paper, its editors, and McNeil should be embarrassed.

“Like Mother, Like Son”

The relevance of this story to the discussion of non-therapeutic child circumcision is obvious:

A Cobb County mother was charged with misdemeanor child cruelty after she allegedly let her 10-year-old son get a tattoo in memory of his deceased brother, Channel 2 Action News reported.
…

Police now want to speak with the person who allegedly applied the tattoo to Gaquan.

In Georgia, as it is in 38 other states in the U.S., it’s illegal to tattoo a minor (O.C.G.A. § 16-5-71). I suspect the comment sections on every news outlet reporting this will be filled with outrage that a parent would do this. Surely some of those commenters, like Georgia’s elected officials, support circumcision imposed at the will of parents. The hypocrisy is frustrating because the that level of cognitive dissonance is so bizarre and the challenge to overcome it so difficult.

To be clear, of course tattooing a minor should be illegal. But I’d add the same qualification I apply to non-therapeutic circumcision. If the individual minor consents, the ethical challenge is resolved. Children are not idiots until their 18th birthday. The child in this story consented to his tattoo. Whether the age of consent should be something higher than 10 is a valid question. I side on “higher”, personally, even though I wouldn’t prosecute here. Still, consent matters.

To the extent that the mother, Chuntera Napier, is correct in this case, she is correct for the wrong reason:

“I always thought if a parent gives consent, then it’s fine,” Napier said. “How can somebody else say it’s not OK? He’s my child, and I have a right to say what I want for my child.”

She’s wrong because she implies the same level of parental ownership that society grants with respect to male circumcision. There is no absolute right to do what a parent wants.

In my legally untrained view I think of circumcision as already illegal with an excused, willful lack of enforcement. The same laws that prohibit harming a child by cutting his arm, for example, should also be sufficient to prohibit non-therapeutic genital cutting. I’m unaware of any “genital cutting (on males only)” exemption. Non-therapeutic circumcision is no more “medical” than non-therapeutic female genital cutting is or non-therapeutic child mastectomy would be.

This lack of enforcement permits parents to offer the nonsensical “like father, like son” to excuse non-therapeutic child circumcision. Many in the medical community push this. In this case, the child’s tattoo is intended to memorialize his deceased brother. Napier also has a tattoo memorializing her deceased son. Why isn’t “like mother, like son” acceptable here? Why use multiple ethical frameworks for issues relating to children, if not to cherry-pick for outcome? Because one violation is uncommon and the other is practiced more than one million times each year? I’m curious to know because the answer isn’t logical.

Flawed Circumcision Defense: Dr. Paul Rein

As activists we’ve all encountered poorly thought out, often incomprehensible arguments advocating for non-therapeutic child circumcision. In their mildest forms, these merely conclude that parents should do what “works for their family”, as if all penises in the family belong to the parents. In their worst form, they’re clueless, uninterested in learning, and offer any number of bizarre justifications that defend the decision while remaining ignorant of basic facts. This essay by Dr. Paul Rein is built on the latter foundation, with the surprise of an irrational excuse for surgically altering healthy boys that I’ve never heard before.

After an introduction and a brief, incomplete history of circumcision, Dr. Rein quotes Genesis 17, including the bit about circumcising one’s slaves. In response, he writes:

… WOW, pretty powerful stuff when taken literally. So why do you think this “law” came about? For me, like Jewish dietary laws (sic) it was all about health. In days past, before modern times, food such as a pig was not considered ok to eat by the Jews because pigs were dirty, ate garbage and carried worms. Bottom feeders in the waters fall in the same category. Circumcision was a matter of numbers of complications for not doing it. Circumcision is done on day 8 of life for what reason? Is there something magical about day 8? It turns out that on day 8 of a boy’s life his blood clotting factors are normal, such that his risk for bleeding is less. In most countries of the world where babies are delivered in the hospital a circumcision if performed is done in the first couple of days and the babies are given a shot of Vitamin K which helps the blood clot, in other words it is a convenience to be done then. Surely the Jews figured out by trial and error that day 8 was the earliest, best and safest time to perform the circumcision. Most likely their dietary laws also discovered that eating pigs caused more illness than not eating them. So lets get back to circumcision.

This is conjecture. It shows the logic-optional framework upon which Dr. Rein is willing to build his conclusion on non-therapeutic child circumcision. I’d like to see citations for the number of complications throughout history “for not doing it”. But I can accept that without citations because it’s irrelevant to the more immediate question: what is justified today?

For example, whether or not there’s something magical about day 8 or the availability of Vitamin K may be interesting, but neither is a valid defense for circumcising healthy infants. Being convenient doesn’t make it acceptable. Any biological magic of a healthy human’s Day 8 ability to properly clot his blood still applies to his Day 6,574¹ ability to properly clot his blood. But, ethically, only one of those is valid.

When Dr. Rein begins to discuss risks of circumcision, he fails to include a complete list of objective outcomes. Some are possible and some are guaranteed.

… The risks include, pain on performing the procedure, bleeding and infection, irritation of the glans, increased risk of meatitis- which is an inflammation to the opening of the penis, injury to the penis during the procedure, and a belief by some that removing the foreskin decreases sexual pleasure. There are also some people who believe it is a violation of the child’s human rights because they did not consent to the procedure.

He should’ve mentioned that circumcision includes the risks of amputation and death. Those are rare, but if he’s not including the absolute risk of the maladies against which non-therapeutic circumcision is a prophylaxis, a full set of known risks should be included.

He should also state that circumcision leaves a scar. That could lead into an actual discussion of whether the male himself wants that, as well as the intended cost of the surgery, the loss of his foreskin. The foreskin is not, biologically, an inert afterthought. I’m not surprised he would omit this because I don’t think he understands this. But the burden is on him to be educated, not on others to defend why healthy, normal body parts exist.

His advice focuses into one key paragraph:

What is a FAMILY to do when they have a newborn boy? …

Celebrate and not cut his healthy genitals. This is what a family does when they have a newborn girl.

… As I have mentioned in the past it is up to you to make informed choices. You as the responsible adult who has had a child should make an informed decision. Educate yourself as to the benefits and risks remembering that most of the risks are small, but when they do happen to you they are 100% in your experience. Nothing is without risk and you weigh the risk versus the benefit. …

Being the “responsible adult” does not mean that option is valid. Tradition does not justify its imposition. The possibility of benefits, the “responsible adult’s” subjective minimization of the risks involved, or the doctor’s omission of the full costs also fail as justifications. The surgical alteration is not medically indicated or necessary. That is the sole relevant information. Where circumcision is being imposed on another who can’t consent, only medical need can justify it.

… Regarding circumcision if you choose not to have your child circumcised and as an older boy or adult he needs to be circumcised the risks increase. The risk of surgery such as pain, bleeding and infection are higher for older boys and men. …

This logic could be applied to any non-therapeutic surgery one might choose to force on a healthy child, primarily with respect to pain. The claimed inability to remember the pain as an infant does not mean the infant does not experience the pain. As an adult, the individual has the choice to use sufficient pain management. It’s also worth noting that actual need for circumcision is rare. Where an adult male’s circumcision is optional, his preference for the possible benefits demonstrate that he values them more than the costs, including the pain. Infants don’t get that choice.

… If you believe that the pain of a circumcision is traumatic to the child and affects him for the rest of his life then don’t do it. To that I say, c’mon. A newborns brain is immature and the few seconds to minutes of crying is no more traumatic that a night of crying from colic. Does that baby who has colic from a formula become so traumatized that he never wants to drink from a bottle? …

Dr. Rein’s lack of concern for the child and what he may experience from unnecessary surgery is scary. Is “c’mon” the scientific term for a newborn’s pain coping mechanism?

… Arguments such as decreased sexual pleasure from a man’s point of view are pretty tough to make. Do you really know any guys who say, geez I wish ….?

Here I am: Geez, I wish I had my foreskin. I am not alone. Dr. Rein should research the topic before he mocks opinions he does not understand. Research would allow him to reject his own incorrect ideas that are easily refuted.

It gets worse:

… Another thing to think about in making your decision is are you a single mother having this child? Little boys, 5 and up are probably not inclined to have their mom making sure that they are practicing proper hygienic techniques and in light of the fact that the USA has the highest rate of single parent homes in the western world that might be something you want to consider. …

Yeah. I thought I’d heard all the dumb arguments. I’m not pleased to know that more creative stupid excuses develop. Raising children involves teaching them proper hygiene and setting expectations for maintaining that throughout childhood. Dr. Rein’s suggestion is nothing more than telling parents (i.e. the “responsible adults”) it’s okay to abdicate their parental responsibilities because that responsibility is too uncomfortable.

To put it in a different perspective, as someone stated in the comments section of the essay, would it be legitimate to suggest that single fathers have their daughters’ genitals cut because it would be too uncomfortable to monitor their hygiene? Even if I accept the incorrect suggestion that forced, non-therapeutic female and male genital cutting don’t involve the same rights (and ethical) violation, the underlying implication of Dr. Rein’s statement is that parents should act against their child if it’s more convenient for them to do so. All other considerations be damned. It’s about the parents, not the patient. That’s unethical, anti-science nonsense.

Dr. Rein addresses the human rights point, badly:

… Finally the human rights issue is in my opinion a weak argument. As parents we are making many decisions for our children. Children don’t get to make too many medical decisions including vaccinations and antibiotics that are often forced on them when they don’t need them.

This decision is not like other decisions. It’s the unnecessary surgical alteration/reduction of a child’s body in pursuit of subjective outcomes based on someone else’s preferences. Parents vaccinate to protect their children, so, yes, in that limited non-useful manner, vaccinations and non-therapeutic circumcision can be viewed the same way. But the same thing could be said about comparing vaccinations to removing the healthy breast buds of a girl whose family has a history of breast cancer. There has to be more for it to be intelligent and useful. So, vaccinations work to build the body by using its natural mechanisms. Circumcision simply removes a body part that may develop a future problem. Dr. Rein’s comparison is invalid.

If Dr. Rein thinks that the irresponsible use of antibiotics by parents is a defense of the irresponsible use of circumcision, he’s more interested in establishing defenses for his pre-determined conclusion than reaching a conclusion based on facts and logic. I’m going with that because I read his essay. He didn’t provide any evidence for me to conclude otherwise.

¹ Or Day 6,575…

Donations Are Voluntary, Not Taken

Anyone who’s spent a moderate amount of time studying circumcision and the ethical lapses involved understands the vast expanse of those lapses. These are generally thoughtless rather than intentional. Cognitive dissonance has a powerful hold on human beings. Forced genital cutting of healthy children is just one of many absurd, offensive examples.

That said, it’s still disheartening to read stories like this:

… Scientists at a laboratory in Germany have begun growing human skin from the cells of infant foreskins.

According to the German Herald, the “medical breakthrough” is being used to test cosmetics and other consumer products and could someday replace all animal testing. The so-called Skin Factory, at the Fraunhofer Institute in Stuttgart, takes foreskin cells donated to the project and uses them to grow the skin, according to spokesman Andreas Traube.

This is not a “medical breakthrough”. The technique involved may be new, but the process of using infant foreskins is not. Skin cells generated from (healthy) infant foreskins have been used in cosmetics and skin grafting for many years.

The ethics of the “donation” are grotesque:

Traube said the foreskin is taken from children aged 1-4, because the younger tissue has better research applications. “The older the skin is, the worse it performs,” he said. …

“It’s logical that we’d want to take the operation to a bigger scale,” Traube said. “In the future, there are all sort of possible applications for the Skin Factory like cancer research, pigmentation diseases, and allergic reactions.”

Scaling up this operation obviously requires more healthy male children circumcised without their consent. But in pursuit of what goal?

The scientists at the Fraunhofer Institute hope the skin they’ve been able to produce will provide a humane alternative to using animals in testing of cosmetics and other products, a German news service, the Deutsche Presse Agentur, reported.

Obligatory disclosure: I’m a vegan. I understand and care about animal welfare issues. However, I do not place the welfare of animals above – or even equal to – the welfare of humans. The choice here is not to injure or not injure an animal. The choice is to injure an animal or to injure a human. The correct ethical choice is simple to understand when contemplated, however briefly. The scientists (and parents) involved should contemplate them. The sooner they’d like to start, the better.

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On a closing note, from the second article:

For their next project, the scientists are working on reproducing the human cornea.

Do the scientists intend to use “donated” infant male corneas?

Rwanda Imposing a Foreskin-Free Generation

On Monday the Washington Post published a propaganda piece by Rwandan Minister of Health Agnes Binagwahois. She talks writes of “an opportunity to lay the foundation for an AIDS-free generation,” which inevitably means a primary focus on “voluntary, adult” male circumcision. It’s a matter of faith that this will solve everything, and as a result, there must not be any ethical issues to discuss. Anyway, they’re only implementing “voluntary, adult” male circumcision. Just believe.

Experience demands a closer inquiry. When public health officials speak of “voluntary, adult” male circumcision, they never mean voluntary or adult. They say it, as Binagwahois does. That phrase is mandatory. They do mandatory very well.

We have the capacity to save nearly 4 million lives in sub-Saharan Africa, the hardest hit region in the world, by scaling up voluntary medical male circumcision — the best tool we have for HIV prevention. But the only method widely approved for funding is the surgical method, which is expensive and impractical for countries lacking physicians and surgical infrastructure.

She didn’t say adult yet, but that shows up. She writes that “[p]ublic health officials set a goal to reach nearly 20 million men ages 15 to 49 by 2015…”. I’d quibble over a 15-year-old being an adult, but I also think a 15-year-old is capable of informed consent. If only her statement were true.

In the essay she links to a paper outlining Rwanda’s “national goal”, which can be summed up as a willful violation of human rights. From page 61:

High coverage of male circumcision has been shown to be effective in reducing heterosexual transmission of HIV infection. Under this Outcome, circumcision will be promoted to adult males, with the aim of increasing the prevalence of circumcision. In addition, although circumcision of newborn boys will not contribute to the result of reduced sexual transmission of HIV during the period covered by this NSP, it is nonetheless an important long-term strategy for reducing susceptibility to HIV infection in the Rwandan population.

In case it isn’t quite clear enough, the report includes this table:

Figure 18

Then it’s summarized:

Output 1.1.2.1. Newborn boys, adolescents and adults have increased access to circumcision

Key strategies:

  • i. Advocacy for integration of circumcision in minimum package of health centers
  • ii. Promotion and provision of male circumcision for adolescents and adults
  • iii. Promotion and provision of male circumcision for newborn boys

She also links to the WHO’s 2011 revised report, Progress in scale-up of male circumcision for HIV prevention in Eastern and Southern Africa: Focus on service delivery. On page 14 the WHO describes Rwanda’s current “Service” delivery strategy.

Plans include the integration of MC into existing services with campaigns and mobile services to increase coverage. Service delivery has begun at selected sites, including military settings. Neonatal and adolescent MC is articulated in the longer-term plan.

About that “long-term” plan. Rwanda keeps saying “long-term”, but a close look at Figure 18 shows its definition. Rwanda’s target for 2012 is 50% of all newborn males. Rwanda is actively circumcising newborn males now. The limitation is clearly not intent. I believe they are sincere in focusing on adults, although less so on the “voluntary” aspect. But it’s obvious where the real focus is. Fear of HIV in the presence of effective-but-elective non-surgical interventions leads to a blatant disregard for the rights of children. It is disgusting.

Since there is a national plan to circumcise newborn and adolescent males without their consent, why does Binagwahois not say so explicitly? Instead, she pretends that the current focus is only on adults and limits herself to advertising for the “non-surgical” PrePex device. Since she doesn’t know the meaning of voluntary or adult, it isn’t particularly surprising that she doesn’t understand the definition of surgery. The ability to limit bleeding does not mean it is non-surgical. Condoms are non-surgical. Foreskin removal is surgical. It’s not refuted just because the device’s manufacturer says so. Regurgitating marketing material is not supposed to be the job of a public health official.

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For consideration relevant to the ethics and practicality of the PrePex rollout, Figure 6 in the study (NSFW) Binagwahois’ essay links suggests to me that there will be complications when use of this device is scaled to 20 million men in field settings. And to be fair to Circ MedTech, it promotes PrePex for adult male circumcision. We’ll see if their focus remains on voluntary, adult male circumcision.