Category: Ethics

Giving Accidental Legitimacy to Flawed Terminology

This almost-good post from the AHA Foundation, FGM is Not Female Circumcision, and Other Thoughts on Terminology, is worth discussing for the reason it is not good.

The premise that female genital mutilation (FGM) is not “female circumcision” is correct. Language matters. In basic semantics, calling FGM “circumcision” is inaccurate. The etymology of the word circumcision means “to cut around”. That can be done to the female prepuce, in a sense, but that’s not how we understand it. I’m willing to grant this, and the result that the term circumcision doesn’t apply to females.

The gist of the AHA Foundation’s post is about the ethical implications from terminology:

A number of organizations and advocacy groups refer to the procedure as “female genital cutting”, or “FGM/C” to encompass both terms. The argument for “cutting” instead of “mutilation” primarily hinges on the belief that mutilation implies malicious intent on the part of parents or the community, or is otherwise demeaning or insensitive to the cultural particularities of any group that performs FGM. Some argue that referring to it as cutting is a less provocative and more balanced term. Particularly when speaking with those who have undergone the procedure themselves or in reaching out to affected communities, we do see the value in using the more neutral terminology of “cutting” rather than “mutilation”, but otherwise believe it important to state clearly that the procedure is a form of abuse.

I agree with that. What is done to the healthy genitals of females without their consent in any form of FGM/C is morally and ethically wrong. It is indefensible. We must be clear that this violence is abuse. It should never be tolerated.

The AHA Foundation’s post fails because of its next-to-last paragraph.

The argument for referring to FGM as “female circumcision” is blatantly off-base. Female circumcision was the popular term until approximately the 1980s, when FGM and FGC came into usage. As mentioned above, to perform a procedure that parallels male circumcision, one would only remove the prepuce of the clitoris, something that is hardly ever done. (The prepuce is the “hood” or fold of skin that surrounds the clitoris and has no impact on sexual arousal or pleasure.) In nearly all cases, at minimum, either part or all of the clitoris, labia minora, labia majora is removed. To use the term “circumcision” to refer to what is happening to these girls minimizes the brutality of the procedure and ignores the fact that is an act of violence.

First, the paragraph is likely factually wrong when stating the clitoral hood has no impact on sexual arousal or pleasure. It’s bizarre that this made it into the post. I suspect the connection is an implication that the male prepuce also has no impact on sexual arousal or pleasure. Whether the clitoral hood affects arousal or pleasure, its removal would alter the woman’s sexual experience. That is a reason removing it without the individual’s consent is unethical. The parenthetical makes no sense.

To my point, since the post brought it up, what parallels male circumcision is not the only consideration. There are recognized forms of FGM/C less harmful than male circumcision. Much, if not all, of Type IV is comparable to or less harmful than a typical male circumcision. The stated, correct argument against FGM/C in the post (and elsewhere) is that any genital cutting on a female without need or her consent is wrong. (Including removal of the prepuce.) Any lesser conclusion or implication for male circumcision is moral relativism.

The paragraph’s flaw is its implication that FGM/C should not be called circumcision because circumcision is not a brutal act of violence. I doubt this is what the author means. I trust that the AHA Foundation recognizes that males possess the same “basic rights and freedoms” listed on its About page, including “security and control of their own bodies”. But the argument in that paragraph is predicated on minimizing a form of genital cutting, and based solely on gender. The general thrust of the debate is that FGM/C is often done with crude instruments in unsanitary conditions. It is. However, no one suggests that FGM/C performed in a hospital setting with clean instruments is somehow acceptable. At its core, cutting healthy genitals without the person’s consent is the issue.

The accurate approach would’ve been to leave out male circumcision and focus the paragraph accordingly. It would not be difficult. For example: “The term circumcision minimizes the brutality of genital cutting without need or the individual’s consent and ignores the fact that it is an act of violence.”

I do not believe those focused on ending FGM/C are required to actively advocate against male circumcision genital cutting. I expect them not to state or imply that male genital cutting without need or consent is acceptable. I expect them not to do this, from an exchange that started with the bottom tweet¹:

They responded to me:

We’re not advocating for anyone to be cut, only trying to point out the severity and harm done with #FGM.

I recognize that, as I indicated. But the response to Mr. Cummins was incorrect. There is no excuse for saying something false. (Or following up in agreement to his ad hominem.)

An organization that carelessly ignores the broader foundational principle to its work deserves no credibility. Every point that rejects FGM/C in the post applies to male genital cutting. In the points where the severity between the two is almost always different, and radically so, that is a critical distinction I’ve highlighted before. But something that should inform punishment rather than legality should not be used so recklessly. FGM/C isn’t made less terrible just because generally less-severe male genital cutting violates the same principle. Yes, those against forced male genital cutting need to be responsible when interjecting into a discussion on FGM/C, including by doing so less often. The same need for responsibility holds true for those who advocate against FGM/C.

¹ Contrary to Mr. Cummins’ rant, the argument is that non-therapeutic genital cutting on a non-consenting individual is wrong. There is almost always a difference in the degree of harm imposed from male and female genital cutting. It is often significant. But as the information in the AHA Foundation’s post also demonstrates, there is no difference in kind.

The AAP Discounts Its Patients’ Right to Physical Integrity

In “Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision”, Morten Frisch, MD, PhD, et al (pdf) criticize the AAP’s revised policy statement on circumcision. In part, they state:

The most important criteria for the justification of medical procedures are necessity, cost-effectiveness, subsidiarity, proportionality, and consent. For preventive medical procedures, this means that the procedure must effectively lead to the prevention of a serious medical problem, that there is no less intrusive means of reaching the same goal, and that the risks of the procedure are proportional to the intended benefit. In addition, when performed in childhood, it needs to be clearly demonstrated that it is essential to perform the procedure before an age at which the individual can make a decision about the procedure for him or herself.

They raise many issues surrounding the AAP’s focus on UTIs, penile cancer, STDs, and HIV. They conclude that non-therapeutic circumcision “fails to meet the commonly accepted criteria for the justification of preventive medical procedures in children.” Even ignoring their critique of the applicability of the scientific studies involved in the AAP’s revised policy statement, they are convincing. Their ethical argument is powerful.

The response by the AAP’s Task Force on Circumcision is intriguing and bizarre. It’s intriguing because it raises potential issues with what Frisch et al wrote about the science. This section is worth discussing, but not by me. I see the points on both sides. It’s difficult for either to squeeze every helpful detail into a few pages. For this, I’ll leave it with my usual statement. I am willing to accept the claimed benefits, however faulty they may be. The ironclad ethical case against non-therapeutic child circumcision is no weaker if all of the AAP’s criticisms have full merit.

Its response is bizarre for the ethical issues the Task Force continues to dismiss and ignore.

First, responding to the claim that the Task Force suffered from cultural bias:

… Although that heterogeneity may lead to a more tolerant view toward circumcision in the United States than in Europe, the cultural “bias” in the United States is much more likely to be a neutral one than that found in Europe, where there is a clear bias against circumcision. …

That (claimed) neutrality is the problem in the AAP’s revised policy statement on male circumcision. They imagine that there is no right answer to this ethical question. Here, the physical integrity of a healthy child is surgically violated without his consent. The law recognizes a single correct answer for female minors on the same ethical question. The implicit conclusion that male minors possess a lesser right to their physical integrity than their sisters is indefensible. It doesn’t matter that potential benefits exist from circumcision. Frisch et al demonstrate this in analyzing the difference between consent and proxy consent for a non-therapeutic intervention.

The AAP continues its challenge:

… Yet, the commentary’s authors have, at no point, recognized that their own cultural bias may exist in equal, if not greater, measure than any cultural bias that might exist among the members of the AAP Task Force on Circumcision. If cultural bias influences the review of available evidence, then a culture that is comfortable with both the circumcised penis and the uncircumcised penis would seem predisposed to a more dispassionate analysis of the scientific literature than a culture with a bias that is either strongly opposed to circumcision or strongly in favor of it.

So, basically, the AAP’s Task Force is saying “I’m rubber, you’re glue”.

To the point, Frisch et al show that the cultural acceptability of circumcision is not a valid defense because there is a right answer to the ethical question involving this prophylactic surgical intervention on healthy children. The AAP missed the essential issue in its recommendation. The ongoing American experiment with circumcision is a reasonably-inferred explanation. Frisch et al emphasize the child in non-therapeutic child circumcision. The AAP continues to emphasize only circumcision, with the children being a distant abstract. That is the problem, regardless of the reason.

For the purpose of those paragraphs, I pretended that the AAP’s claim that the US is neutral on infant circumcision isn’t laughable nonsense. On the basis of individual opinions, I think we’re probably the fifty-fifty nation they imagine. Institutionally, both medically and politically, we are very much a pro-circumcision nation. The Task Force stated a truth, while missing it, in its Technical Report:

… Reasonable people may disagree, however, as to what is in the best interest of any individual patient or how the potential medical benefits and potential medical harms of circumcision should be weighed against each other. …

The factually-unprovable statement in the Abstract that the “preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure” is the evidence that the AAP is not a pillar of neutrality on non-therapeutic male child circumcision. The Task Force thinks the subjectivity it mistakenly presents as a valid general conclusion in its Abstract may reasonably be taken into consideration for circumcising an individual by proxy consent. If they understood the ethical implications, they would acknowledge that it must only be taken into consideration by the individual for his own healthy body. The neutral position presents facts and lets the individual choose. The biased position lets someone else impose a permanent, unnecessary intervention for the individual.

The Task Force includes a section, Age at Circumcision, in which their argument is that many minors make their sexual debut before the age of majority and some of those people are irresponsible with regard to condoms. The Task Force argues these two facts render it acceptable for parents to make their son’s circumcision decision for him. It views parents through an ideal, rather than the reality of human decision-making where a child must live with the permanent consequences of an unnecessary decision. Individuals are just part of a statistic.

When the Task Force finally gets to the ethical issues, it whiffs again:

… The authors’ argument about the basic right to physical integrity is an important one, but it needs to be balanced by other considerations. The right to physical integrity is easier to defend in the context of a procedure that offers no potential benefit, but the assertion by Frisch et al of ‘no benefit’ is clearly contradicted by the published scientific peer-reviewed evidence. …

Because there are potential benefits, we may discard the supremacy of the basic human right to physical integrity for the healthy child? That’s ridiculous. They don’t say it directly, but their conclusion for parents making their son’s choice endorses it in reality. With this thinking, any number of extreme surgical interventions could be justified on a healthy child because they might offer some benefit at some point. We should at least research any possible intervention to make sure we’re not missing some benefit that could decrease some risk, if that really is an acceptable approach. Or we could be rational and set aside our long-held cultural acceptance of this unethical procedure, but that’s harder to defend than fear, I guess.

The second statement, the “assertion by Frisch et al of ‘no benefit'”, is not supported by my reading of their paper. They do not state there is ‘no benefit’ to circumcision. They question the strength of the benefits and their applicability to children, particularly because less intrusive methods to achieve these benefits are available. The Task Force builds a straw man instead of confronting the ethical issues.

Finally, the Task Force asserts the “right to grow up circumcised“:

Frisch et al appeal to the ethical precept “First, do no harm,” but they fail to recognize that in situations in which a preventive benefit exists, harm can also be done by failing to act. Whereas there are rare situations in which a male will be harmed by a circumcision procedure, …

I’m interrupting the excerpt to correct this inaccurate statement. Every circumcision inflicts harm, including loss of normal tissue and nerve endings, as well as scarring. Some circumcisions inflict more harm than expected or intended. The Task Force conflates intent and outcome.

… it is also true that some males will be harmed by not being circumcised. Simply because it is difficult to identify exactly which individuals have suffered a harm because they were not circumcised should not lead one to discount the very real harms that might befall some men by not being circumcised. …

I don’t discount the real harms some will experience from the risks in being alive with a normal human anatomy. I dismiss their relevance in this context. It’s a dumb standard for evaluating what may be done to a healthy child without his consent. Life can never be lived without risk. If a male is worried enough about the minimal risks posed by his foreskin, he can elect to be circumcised with his own informed consent. But the reverse is not true. A male who is circumcised at birth can’t recover his foreskin if he would not trade his foreskin¹ for the proposed benefits. Individual choice is the valid, superior ethical position.

Their conclusion:

… There is no easy answer to this issue ethically. Regardless of what decision is made on behalf of a young male, harm might [ed. note: will, if the decision is circumcision] result from that decision. That is precisely why the AAP task force members found that this decision properly remains with parents and that parents should have information about both potential benefits and potential harms as they make this decision for their child.

There is an easy answer to this issue ethically. Non-therapeutic genital cutting on a non-consenting male is unethical. It inflicts guaranteed harm to minimize already tiny risks. This is the same easy answer we draw for females. We know parents shouldn’t make this decision unless it is “necessary to the health of the person on whom it is performed” when the person on whom it is performed is female. We’ve legislated this knowledge. The right to physical integrity is easy to defend. The AAP has an ethical duty to defend it for all children, including males.

¹ Full quote from AAP Task Force on Circumcision member Dr. Douglas Diekema: “[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.”

Genital Mutilation Is One Cause

Owen at Oggy Bloggy Ogwr posted a fascinating discussion on International Women’s Day – Life, Ethics & Independence III – Circumcision. He’s thorough and makes a strong case, summarized with this:

I think the point I’m trying to make here is that perceived injustices that might be deemed “the same cause” for both sexes might not be similar at all. It’s issues like this that mean we have/need an International Women’s Day in the first place.

There are millions of women who currently have to endure some of the worst abuses humankind can throw at them for simply being born the “wrong gender”, and who don’t have much of a voice – except on days like today.

His post is strong because he addresses the issues involved rather than defending International Women’s Day with the rhetorical equivalent of “Shut up, men”. I disagree with very few of his points in the post. However, those few lead me to disagree with his defense of his conclusion, while accepting his conclusion that there is value in addressing the injustices women and girls still face and doing so on their own. Basically, his second paragraph stands without the incorrect qualification presented in the first.

My primary disagreement is here:

Is there a double standard here?

Uh….no.

If female circumcision only ever involved removing the clitoral hood – the female equivalent of a foreskin – and was still deemed “genital mutilation” then you would have a point. I doubt you can compare this with women making an informed and conscious choice to have various “body modifications” either.

The UK and US anti-FGM acts prohibit all non-therapeutic female genital cutting, including that which is analogous or less damaging than male circumcision. They prohibit “procedures that intentionally alter or injure female genital organs for non-medical reasons.” The WHO fact sheet on FGM defines it as “removing and damaging healthy and normal female genital tissue, and interferes with the natural functions of girls’ and women’s bodies.” All non-therapeutic cutting on a female without her consent is (rightly) considered mutilation.

Male circumcision fits within both descriptions above, as well as the definition of mutilation. There is no valid reason to distinguish non-therapeutic genital cutting on a non-consenting individual as mutilation or somehow not. The lack of consent to any level of permanent, non-therapeutic surgical harm is the critical issue in identifying genital mutilation. Male circumcision or hoodectomy or any other non-therapeutic cutting is ethically acceptable only when voluntarily chosen by the individual receiving it. Proxy consent is still lack of consent.

I recognize the often great difference in severity from what is typically done to males and females. That matters, and should inform penalties, whether criminal or civil. This difference should not inform legality. (The challenge of enforceability can’t be ignored, of course, but that’s separate from what “should be”.) As I’ve said before, a punch to the face is still battery even though a knife to the gut generally causes more damage.

To be fair, Owen made it clear that he understands the problem inherent in male circumcision. He disagrees with imposing it on children. I am not saying anyone needs to fight male circumcision in their fight against FGM, even though they are the same cause in principle. My point is that FGM is bad enough on its own that making that case doesn’t need a separation of male circumcision from mutilation. This is also true because separating male circumcision from mutilation is counter-factual.

(Conversely, the case against male circumcision can be made without a comparison to FGM.)

Dr. Douglas Diekema: Still Inconsistent on Circumcision

Inevitably, whenever a new study suggests that circumcision may not be a panacea of benefits without costs, dismissal follows swiftly. That isn’t the problem. Skepticism is always warranted, and sometimes, criticism is also warranted. I do wish more people, particularly journalists, would adhere to that when pro-circumcision studies are published, but c’est la vie. The facts are on our side in this (unfortunately) long effort. The key is getting to facts.

With the recent study confirming “the importance of the foreskin for penile sensitivity, overall sexual satisfaction, and penile functioning”, the refutations have begun. When Dr. Douglas Diekema criticizes, odd bouts of cognitive dissonance are almost guaranteed. Here, Dr. Diekema joins the rebuttal¹ to this study with his unique way of missing a much-needed chance for self-examination.

“The study is pretty flawed,” said Douglas Diekema, a pediatrics professor at the University of Washington, who was part of the American Academy of Pediatrics 2012 task force on circumcision. “I read the conclusion and then I read the study, and I said, ‘Wow, they went overboard in what they’re concluding.'”

If only Dr. Diekema, a member of the American Academy of Pediatrics (AAP) Task Force on Circumcision, always cared about having the details match the conclusion, with not going overboard in a conclusion. For example, in the AAP’s revised policy statement on circumcision, the technical report states (page 759):

… Reasonable people may disagree, however, as to what is in the best interest of any individual patient or how the potential medical benefits and potential medical harms of circumcision should be weighed against each other. …

That’s the core truth for any non-therapeutic intervention, which clarifies the ethical flaw in proxy consent for non-therapeutic circumcision. What does the individual who doesn’t need circumcision want for himself?

Yet, in the abstract for its revised policy, the AAP bizarrely concludes:

Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; …

The statements in the technical report and the abstract do not say the same thing. The details do not support the conclusion. The abstract states an opinion that the technical report makes clear is not universally true or applicable to any specific individual male. Dr. Diekema once stated (correctly) that “not everyone would trade that foreskin for that medical benefit.” Yet, he stands behind the revised policy that encourages proxy consent for non-therapeutic circumcision while maligns those who criticize the report for its obvious flaws. He’s made these contradictory statements for more than a year. At some point maybe he’ll stop doing that, or he could even embrace the ethics involved that require rejecting non-therapeutic genital cutting on a non-consenting child. I can hope.

¹ The study may be flawed, and perhaps in exactly the way Dr. Diekema states. I don’t wish to engage in confirmation bias merely because I like the findings. Anyway, I don’t need the study. The principled ethics matter more than whether circumcision is “good” or “bad”, both subjective to the individual foreskin owner.

We Must Do Better

There’s a circumcision flowchart floating around that needs to be addressed. Here it is:

Flowchart1_resized

It fails from the start. The right first question is “Is there a medical problem with the foreskin?”, or something similar. That will get the circumcision decision process started.

“Do you have a penis?” is never a relevant question. It’s a sexist approach that fails to promote the critical, universal genital integrity rights involved. Fathers and mothers are equally capable of offering good and bad arguments on non-therapeutic child circumcision. We must address individuals, not generalizations. The latter leaves us making ineffective arguments to proponents who might be willing to change their mind to protect their son(s).

To put it in perspective, am I not allowed to denounce non-therapeutic female genital cutting because I don’t have labia or a clitoris? The idea is ridiculous. The human rights issue is first. We’re all capable of using our intellect and reason to understand genital integrity. Let’s use them and expect others to do the same.

If we start with awful premises, we interfere with our objective of protecting the bodies and rights of children. If we promote the idea that some people are inferior, they will tune us out when we state that all people should be treated equally. Please, stop promoting this flowchart. We can be better than this. We must be.

P.S. Shut up also needs to go.

Ghana Encourages Unethical Infant Circumcision

As always, when public health officials endorse voluntary, adult male circumcision to reduce the risk of (female-to-male) HIV transmission, they never mean voluntary or adult. Today, Ghana:

Dr Gloria Asare, a Public Health Consultant, has said male circumcision was one key area of HIV and AIDS prevention and appealed to families to circumcise their male children.

Someday we won’t let good intentions and fear blind us to the fatal ethical flaw within non-therapeutic infant circumcision. We will endorse and require consent from the patient rather than proxy consent for the patient.

International Day of Zero Tolerance to FGM, 2013

Today is International Day of Zero Tolerance to Female Genital Mutilation. The WHO statement on this is lacking, which I don’t find surprising. (emphasis added)

The International Day of Zero Tolerance to Female Genital Mutilation is observed each year to raise awareness about this practice. Female genital mutilation of any type has been recognized as a harmful practice and violation of the human rights of girls and women. WHO is committed to the elimination of female genital mutilation within a generation and is focusing on advocacy, research and guidance for health professionals and health systems.

Female genital mutilation (FGM) refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons. Female genital mutilation has no known health benefits. On the contrary, it is associated with a series of short and long-term risks to both physical, mental and sexual health and well-being.

FGM is affecting about 140 million girls and women, and more than 3 million girls are at risk every year. A special focus for WHO this year, is the troubling trend of health-care providers increasingly being the ones performing female genital mutilation, and thereby contributing to legitimize and maintain the practice.

Today, I’m not going to discuss the comparison to male circumcision beyond the one inherent in this sentence. I am going to use WHO’s approach to male circumcision to compare why its last sentence shouldn’t be a surprise.

Stating that FGM has no known health benefits works from the premise that the possibility of benefits could justify FGM. No benefit could justify forced FGC (i.e. mutilation). The human rights principle is superior. WHO should state that as its foundation, and be consistent and repetitive. In reminding readers about this lack of benefits, WHO almost apologizes for being against FGM. The absence of benefits is not why this shouldn’t be done.

Think back to when the AAP issued a revised policy statement on FGC, later retracted. As I wrote here and here, I didn’t/don’t think it said what people read into it. But the reaction was universal and swift. On the idea that permitting limited forms of genital cutting could prevent greater harm to females, activists stood on the absolute principle. Whether or not this makes sense is a worthwhile discussion. (My posts linked above set out my thoughts on the issue. The principle still matters more.) Regardless, that incident demonstrates that activists would never excuse FGC/M if benefits were proposed or found. Can anyone imagine a scenario where any scientific committee allowed research into possible benefits? For those inclined to accept possible benefits as a justification, everyone else must discourage this thinking. Lazy statements that lack the courage to defends what is morally and ethically correct fail that goal.

WHO’s approach, which informs its stance on male circumcision, enables the predictable problems described in the last sentence. Because the organization refuses to stand for principle where courage is necessary, it creates the conflict of legitimizing genital cutting through “medical” male circumcision programs. I know of no populations that cut females that don’t also cut males. So, WHO drives campaigns to legitimize genital cutting while driving campaigns to delegitimize genital cutting. The flaw is obvious. The principle and consistency matter.

Dumbest Sentence I’ve Read Today

From the Anne Arundel Medical Center’s information page on (infant) circumcision, in the “How is circumcision performed?” section:

Circumcision is performed only on healthy babies.

I will never understand how medical service providers can recognize that and still think nothing is wrong with their participation in their imposition of this non-therapeutic surgery on their patient.

We Were All Female. We Are All Humans.

Here’s a fantastic video from AsapSCIENCE:

It’s an oversimplification, but barely, to say that we all have the same parts. They look different but start as the same. We are equal. There is no reason to imagine that the damage from non-therapeutic cutting of male genitals is acceptable in the way we reject as obvious for any female genital cutting. We all begin with a common foundation. Yes, the intent – and often, extent – can be quite different. We must not forget or ignore that. But that isn’t enough. It’s possible to recognize the rights of boys without minimizing or easing protection against what is done to girls. The issue remains that permanent harm results from non-therapeutic genital cutting.

Society has developed irrational rules that somehow the basic human rights to genital integrity and bodily autonomy splinter after the first six weeks of fetal development. Females maintain this right, but once the Y chromosome becomes dominant, legal and ethical concern for this right inexcusably diminishes among too many. We should not behave this way. The above video demonstrates that this distinction is false. Boys deserve their human rights, too.

Video via Geeks are Sexy.