Category: Logic

Dr. Lindsey Doe on Dealing with Sexual Injustices, Including Male Circumcision

Dr. Lindsey Doe, a clinical sexologist, hosts sexplanations on YouTube. It’s an excellent show that educates viewers on human sexuality. In the latest episode, “How to Deal with Sexual Injustices”, she talks about injustice with a focus on male circumcision. She is spot-on in her analysis and how to approach this injustice on a personal level. Please watch. (It’s obviously NSFW based on strong language and topics.)

The circle she created about circumcision is an excellent starting point. (Here’s a screencap of that circle.)

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.”

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.

The Case Against “The Case Against Intactivism”

If you’ve read my work here (or on Twitter) for any length of time, you know that I don’t agree (e.g.) with every tactic used to argue for genital integrity. I’m not arrogant enough to assume I’m always correct, but my experience has to inform the means I endorse in pursuit of the necessary, noble goal. Where I think we’re making mistakes, particularly predictably ineffective mistakes, I speak out. I know enough people within the genital integrity movement to know that the principled, decent strategy is the most common.

That said, I’m not willing to paint broadly based on the actions of individuals. This can be either good or bad actions. One person expressing an idiotic excuse for circumcision do not mean everyone who shares a characteristic would defend that excuse. I do this because it’s fair and because I do not want this approach applied to me. It will always be possible to find genital integrity activists who engage in inexcusable behavior, such as anti-Semitism. I can make my case without that, as can most activists. Principles and tactics are associated, but the former exists apart from the latter.

This is why the website The Case Against Intactivism frustrates me so greatly. It is run by blogger “paper0airplane”, who is against routine infant circumcision while lumping any bad behavior by those opposed to circumcision into the “intactivism” category. This is wrong. For example, I spoke out when issue #2 of “Foreskin Man” appeared, long before it made news during the San Francisco ballot initiative in mid-2011. I was not alone. Should we all be blamed for this comic book, or are individual – sometimes egregious – mistakes inevitable in any decentralized movement? The answer is obviously the latter, but paper0airplane consistently writes as if it’s the former. That is what I wish to reject here.

In July paper0airplane posted this:

… My opinion also hasn’t changed. I do not circumcise, I don’t think circumcision is necessary. I also do not approve of the tactics used by intactivists, and were they to change those tactics, I would support them wholeheartedly. Much like the rabid pro-life crowd, intactivists generally resort to appeals to emotion, twisting of facts, offering up studies (that they haven’t even read) claiming they say one thing, when in fact they do not (relying, instead, on the fact that many will not actually read the study, simply providing one counts as support of their argument), sometimes outright lying. That includes setting up studies in such a way as to pre-determine the outcome. These are things that I disagree with, and will continue to disagree with. Since most intactivists, instead of actually reading my site objectively, believe that I am actually pro-circumcision and that my site advocates for circumcision, I’m attacked quite often. …

People who can be classified as intactivists cannot be neatly stuffed into a box labeled “Endorses These Tactics”. I am an intactivist, although what I wrote in 2006 still holds. The term intactivist is cute and descriptive, but because it’s cute, I do not like it. It does little more than give reporters an excuse to fill in stories with details at which typical readers will roll their eyes. That’s not helpful. The term has gained wider acceptance, but it’s still treated in much the same way in many places. And paper0airplane uses it as a convenient stereotype.

So, from that July post, in order:

  • Generally suggests stereotyping. That should be a signal that the critique is shaky. Not necessarily flawed, but evidence is required and should be drawn from and applied to the person(s) using the criticized tactic.
  • Appeals to emotion as a tactic is the least effective approach. Those who use it exclusively need to expand their repertoire. But its use, even exclusively by some, says nothing about intactivism as a whole.
  • I do not twist facts. Grinding this axe with a blunt dismissal of all rather than against the few who deserve it impedes my efforts. If paper0airplane insists on grouping everyone together, prove that I’m the hack caricature with examples. Otherwise, I’m left to assume that paper0airplane is a lazy thinker and writer. (The body of work that assumes any intactivist is all intactivists is evidence of this.)
  • I do not defend studies I know to be flawed. I’ve long held that the “estimated number of deaths” study is flawed¹. Conversely, I’ve also demonstrated that the “circumcision makes no difference to sexual sensitivity/satisfaction” studies are flawed. Should this count as an argument against all proponents of child circumcision or just those who fallaciously treat this issue as settled science based on these flawed studies? There are proponents who are very much lying propagandists. There are also proponents who are sincere and honest but insufficiently informed. I prefer to deal with who is in front of me rather than the worst of everyone I’ve ever encountered.
  • I’ve read enough to know that paper0airplane is opposed to routine infant circumcision. I also know that paper0airplane defends ritual circumcision. I disagree with this because the arguments against non-therapeutic circumcision, both ethical and scientific, apply to males born to religious parents. I do not wish to imply that change will be easy, only that change is necessary, as various reforms throughout history have been necessary. We are not at the pinnacle of balancing religion and rights. (More on this in another post.)

Going back to paper0airplane’s first post, this:

There are many many very reasonable people that label themselves intactivist. They’re nice people are are just as interested in the truth as you or I. Unfortunately, the loudmouths at the front are doing all the damage. They color public perception of what intactivism is. I think we can greatly reduce the number of circumcisions without being total A-Holes or alienating all our circumcising friends and family. Without being bullies. Because that’s what intactivists are represented by. Bullys. To the reasonable people that label themselves intactivist, I beg you! Find another way to label yourself! People will be more likely to listen if you don’t have to carry the intactivist baggage around.

This paragraph demonstrates my point. There are intactivists who use problematic and/or unethical tactics. Again, this is inevitable in any decentralized movement, just as one can easily find examples of the same among circumcision proponents. It’s possible to challenge, refute, and/or discredit “the loudmouths” without dismissing everyone by stereotyping on the behavior of a subset. I wish paper0airplane would make that effort instead of indiscriminately smearing good and bad activists as the same.

¹ While this study is not something I trust or cite, the number of deaths from non-therapeutic child circumcision is objectively non-zero. That is a fact. How many deaths from non-therapeutic genital cutting on a non-consenting minor do we need before we can demonstrate the ethical case against prophylactic child circumcision? The mere risk of one is enough, but one death is certainly too many. I suspect paper0airplane agrees, although that makes the accompanying defense of religious circumcision of children indefensible. Ritual circumcision of minors is no less an affront to human rights than cultural circumcision.

Too Young To Remember

In an article about an Australian couple arrested for “allegedly organising the illegal circumcision of their one-year-old baby girl in Bali,” this anecdote from Edith Cowan University’s head of medical sciences Moira Sim about patients she has treated is insightful:

She said the women she treated did not see the mutilation of their genitals as an issue because they did not remember having the procedure.

That’s a defense for male circumcision so commonly offered in the United States. Yet, in this anecdote, it’s clear how irrelevant their opinion is as a defense. The violation occurred, and we can easily assume that these women would not feel that way if they hadn’t had their genitals mutilated as children. Ex post facto defenses of non-therapeutic genital cutting offered by the victim, or an assumption that the recipient will develop a specific opinion, can never justify imposing the procedure on a minor.

Adult Circumcision Healing Time

I want to revisit the AAP’s technical report accompanying its revised circumcision policy statement. In the Ethical Issues section, on page 760, this:

… Parents who are considering deferring circumcision should be explicitly informed that circumcision performed later in life has increased risks and costs. Furthermore, deferral of the procedure also requires longer healing time than if performed during the newborn period and requires sexual abstinence during healing. …

This is so often repeated that it’s simply become the accepted truth about voluntary adult circumcision. It should be questioned¹. Does circumcision require a longer healing time in adults than if it’s forced on infants? Evidence suggests this is overblown, at best.

From a 1999 paper by Daniel T. Halperin, PhD and Dr. Robert C. Bailey, “Male circumcision and HIV infection: 10 years and counting”:

By avoiding this issue althogether (sic, medical professionals and public-health authorities may inadvertently be harming the very individuals whom they are trying to help. As increasing numbers of men and boys turn to circumcision as perceived protection from AIDS, many will be exposed to harm by untrained practitioners who use unsafe methods. Yet, contrary to some popular misconceptions, safe and inexpensive male circumcision is routinely performed in developing countries in clinical settings. The procedure is normally performed on an outpatient basis with local anaesthesia, and most men return to light work activities the next day.

From the Brian Morris et al. paper I didn’t like, in the “Absence from work or school” section on Page 10 (pdf):

Unlike the convenience of circumcising a baby that (sic) sleeps most of the time and is a dependent in society, circumcision during productive work or school years will typically require taking time off, although the amount of time off required is typically small. In one study of men circumcised with the Shang Ring device, men took an average of 1.1 days off work; 80% were back at work by day 2, with only 20% requiring more than 2 days, and little disruption to activities or discomfort was reported for the week the ring was in place [121]. Eighteen percent of men in the study reported disruption to their work while the device was present, and 30% had not resumed routine leisure activities by 7 days. In the large Kenyan RCT, only 4% of men required 3 days or more before they could return to normal activities [57]. In a study of childhood MC, median times of 5 days to return to normal activity and 7 to return to school have been reported [182]. This may have been because children are usually more active than adults, thus increasing the chances of injury and so prolonging the healing period.

It’s also interesting that the AAP’s claim is unsourced in the technical report. On what evidence do they claim that adult (i.e. deferred) circumcision requires a longer healing time than infant circumcision? It doesn’t seem to be an accurate statement.

¹ The claim that it costs more should also be questioned. If nothing else, the time value of money must be factored in. The several hundred dollars saved now (that will accumulate) must be compared to the present value of the future cost. The unlikelihood of needing circumcision must also be included. If adult circumcision costs 10x more but is only performed in 8% of males, the net effect is that it’s cheaper. No results from such an analysis would change the sufficient ethical argument against non-therapeutic infant circumcision.

Joya Banerjee Misunderstands Opposition to Circumcision

Amazon.com reviews of Tinderbox: How the West Sparked the AIDS Epidemic and How the World Can Finally Overcome It, by Craig Timberg and Daniel Halperin, PhD, are the subject of a flawed essay by Joya Banerjee, titled “How an anti-circumcision fringe group waged an ideological attack against AIDS scholarship”. I doubt Ms. Banerjee wrote the headline, although it doesn’t much matter because she ues the same silly accusation in her article. After an introduction describing Tinderbox, she writes:

One of the preventive measures discussed in the book, male circumcision, has become an unexpected source of controversy. Anti-circumcision activists have hijacked Amazon.com’s “peer review” comments section, which allows readers to vote on which book reviews are helpful. This system has morphed into a vicious game of character assassination by conspiracy theorists who reject decades’ worth of scientific evidence, showing how easy it is for a concerted crusade to squelch good science.

My first response is to ask if Ms. Banerjee has ever been on the Internet before researching this piece. I mean that only partially in jest. This is how every comments section works, with few exceptions. The primary focus for blame here is probably in the design of Amazon’s peer review system, or at least in anyone placing any significant value on its worth in 2012 as the criterion for buying a book with a controversial topic.

She seems to understand this later in her article, which makes her unfocused back-and-forth attack on opposition to circumcision feel more like an agenda than a critique.

Where does all of this leave us? Two diligent and dedicated authors spent years researching the origin, spread, and potential prevention of AIDS in Africa. Two minutes and a few clicks were all that was required for a passionate extremist group to obfuscate and delegitimize their findings in front of one of their most important and public audiences. Having failed to prove their beliefs through scientific evidence, the intactivists decided to have circumcision, and this entire book, judged in the court of public opinion. Unfortunately for the public, this jury was rigged.

If all it takes is “two minutes and a few clicks”, that’s a flawed system, however inappropriate the action motivation’s may be.

She’s ignorantly inflammatory in her article because she does not appear to understand opposition to circumcision. It is not “extremist” to argue that potential benefits learned through adult volunteers do not negate concern for the ethics of applying that science to healthy, non-consenting individuals (i.e. minors). For some reason she never addresses this aspect of the debate. If she were interested enough to become informed, she could’ve challenged this behavior without misstating the facts about opposition to circumcision.

That said, there is a legitimate problem with this strategy. It’s inappropriate. We can do better. The full set of facts are on our side, and we should always act like it.

But, as problematic as this is, it isn’t as widespread as she declares with her bizarre, broad attack. Most who are against non-therapeutic child circumcision do not engage in this behavior or condone it from those who do. The title states that an “anti-circumcision fringe group” participated in this without naming any group. The group is somehow all “intactivists”. That’s irresponsible, bordering on the same type of unfair maligning she criticizes. She writes later in her article:

Although male circumcision occupies less than 10 percent of the book’s pages, it was enough to spark outrage among a tiny but passionately vocal fringe group, many of whom call themselves “intactivists.” They argue that the procedure is a grave human rights violation and are lobbying to ban the procedure in many countries.

Let me be clear: I do not support what happened on the Amazon page for Tinderbox. I didn’t participate. I don’t recall seeing anything resembling an attempt at an organized tactic. I recognize a couple names among those attached to 1-star reviews, and at least one name attached to a 5-star review, but that’s it. The correct way to state the facts here is that a small group of individuals have done this. It is incorrect, and defies common sense, to suggest that those who engaged in this constitute the entire group of people who oppose circumcision (of healthy children), as Ms. Banerjee’s sloppy accusation does.

Look at the numbers, which are no doubt now influenced further (in both directions) by Ms. Banerjee’s article. Consider this sample of the helpful ratings for one star reviews:

  • 91 of 232
  • 83 of 215
  • 81 of 212
  • 124 of 342
  • 76 of 277
  • 52 of 221
  • 33 of 197

Now consider this sample of the helpful ratings for five star reviews:

  • 114 of 129
  • 104 of 133
  • 111 of 151
  • 131 of 186
  • 73 of 135
  • 76 of 165
  • 101 of 153

They look similar¹, right? That’s not to minimize or dismiss (or legitimize) the gaming of the system. And voting down many of the 1-star reviews is probably appropriate. But it can work both ways. Amazon’s review system allows those who support the book to vote down a 1-star review on the basis of it being a 1-star review, without regard for its content. One seems more likely than the other, of course. Reasonable analysis and criticism must still start with the system, not its users. Where the users are wrong, the problem should be identified without hyperbole.

That last rating is also interesting because it’s the rating on the review left by Ms. Banerjee in June.

…
It’s really too bad that the reviews here have been taken over by an ideological group that shuns science and hard fact. This group has mobilized hundreds of people to write bad reviews and then rate their friend’s bad reviews as helpful.

The reviews (by people who obviously haven’t read the book) are really about their opposition to male circumcision, not about the content of the book at all. Which is pretty nonsensical, seeing as how the majority of legitimate public health institutions (including the World Health Organization and UNAIDS) have accepted that voluntary medical male circumcision prevents HIV by over 60%, and long term data shows it protects by 76%! That’s better than even the flu vaccine- so it’s surprising that these ideological quacks would rather let Africans die from a preventable disease than admit they don’t understand science.

Anyway, READ THE BOOK! There were (sic) always be quacks and naysayers out there (akin to those who still oppose the measles vaccine because they think it causes autism). The racist attacks on the author in these reviews do nothing to bolster their credibility!

I haven’t rated Tinderbox because I haven’t read it. I’ve skimmed it to get a feel for its treatment of circumcision. I have an unfavorable opinion about it based on that, but skimming isn’t enough to rate it.

She has read it. That doesn’t excuse that she engaged in nonsense in her review, as she also does now in her current article. It’s odd to suggest that “hundreds” of people are rating the book down when the number that could be attributed to opponents is obviously under 100. Exactly one 5-star review has more than 100 “unhelpful” ratings, and that one belongs to Professor Brian Morris, who engaged in the same sort of unhelpful ad hominem evidenced in Ms. Banerjee’s article. The math doesn’t add up to this being widespread among all intactivists, unless she honestly believes opposition to circumcision consists of fewer than one hundred people. The population who would do this probably is that small, but she painted opposition with the broadest brush possible, as she inexcusably does in her current Slate article.

It’s also silly to assume one has to shun science and hard fact to oppose non-therapeutic child circumcision. I don’t shun either science or hard fact. My position is that there are probably flaws in the methodology, but I don’t worry about them in my position because the correct position starts with present health and the ethics involved in consent. I assume every potential benefit is real, including reduced female-to-male HIV transmission in high-risk populations with low circumcision rates. But I am not a utilitarian who ignores individual rights, including the rights to bodily integrity/autonomy and self-determination. The right to be free from unwanted – and critically in this case, unnecessary – harm supersedes every potential benefit until the individual can weigh in with his personal preference on which he values more, the benefits or his foreskin. Where public policy or Tinderbox limits itself to voluntary, adult circumcision, I have no issues. The former rarely does, to its great discredit. The latter appears to follow the same pattern. For example, in Note 18 on page 352, Timberg and Halperin write:

… There has also been some confusion caused by mistaken comparisons with “female genital mutilation,” which is a very different type of procedure and can have serious negative medical consequences. …

This ignores the science and hard facts of male circumcision. Non-therapeutic genital cutting on a non-consenting individual is unethical whether it’s forced on a girl or a boy. Gender doesn’t matter here because all people, including male minors, possess the same basic human rights equally. That’s the ethical principle being ignored. That must stop.

Timberg and Halperin mistakenly imply that male circumcision is innocuous. All non-therapeutic genital surgeries have negative medical consequences for the individual that he or she may not want. (e.g. loss of foreskin, severed nerve endings, damage to/loss of frenulum) And some number of males have serious negative medical consequences, including partial or full amputation, as well as death. Perhaps they discuss this in the book. From my review of the indexed circumcision segments, I’m not convinced they take this into account. (During my prior reviews of Halperin’s work, most notably in this two part series on an awful paper to which he attached his name, I’ve seen no evidence that he assigns any weight to these facts.)

Continuing with Note 18 on page 352:

… Further confusing the issue of male circumcision are the protests of a small but vocal community of activists who often call themselves “intactivists” because of their belief that the male genitalia should remain entirely intact. This constituency has launched aggressive campaigns, including one that resulted in getting an initiative on the ballot in San Francisco to ban the performance of any circumcisions on minors in the city. California officials later ruled that cities had no authority over medical proceduress (sic). …

Neither I nor anyone I know believes that the male genitalia should remain entirely intact. That’s too simplistic and unconcerned with hard fact. I believe my gentials should have remained intact because I was healthy and my foreskin belonged to me. I believe every other male child’s healthy penis and foreskin should also remain intact until he may choose for himself, even if he ultimately chooses circumcision. The issue is bodily integrity and autonomy, not opposition to circumcision full stop. The San Francisco ballot initiative would’ve prohibited the performance of any circumcision on healthy, non-consenting minors in the city, not “any circumcisions on minors”. Omitting key words incorrectly frames the discussion and dismisses valid ethical (and scientific) concerns.

It’s also indefensible to engage in ad hominem (i.e. “ideological quacks” who “would rather let Africans die from a preventable disease than admit they don’t understand science”), as Ms. Banerjee does, without understanding the necessary qualifiers. Personally, I think everyone should use condoms because they prevent the transmission of HIV. If the adult male is so inclined, he may also volunteer to undergo circumcision. I don’t want anyone to die from HIV, but I don’t want anyone’s rights violated in a condescending good faith effort to force on him what someone else thinks he should want. If Ms. Banerjee wants to limit the discussion to voluntary adult male circumcision, that’s fine. She fails to explicitly limit the application of the science to the bodies of adult volunteers. From what I’ve read of Tinderbox, Timberg and Halperin fail to do so, as well. They should all recognize that they’re ignoring the ethical distinction between voluntary adult circumcision and non-therapeutic child circumcision.

Since this is indirectly a critique of Tinderbox, consider another footnote, note 18 on page 385.

… Meanwhile, some critics have suggested that male circumcision is similar to “female genital mutilation’ because it allegedly also reduces sexual functioning and pleasure. Unlike male circumcision, however, these practices-particularly the most extreme forms such as infibulation-can pose significant health risks for women. …

They’re repeating their error, treating male circumcision as if it carries an irrelevant risk of serious complications. But circumcision also changes the form of the penis, which changes the function. The mechanics are different. Maybe that’s better, maybe it isn’t. It’s unique to the individual, contrary to the majoritarian argument they’re about to make.

… In the rigorous studies that have investigated male circumcision’s effect on sexual pleasure, (115-28) nearly all men and their female partners report that after men become circumcised sexual pleasure is the same or enhanced, for both partners. During the 2005-2006 Swaziland pilot circumcision program mentioned in chapter 26, many women began saying that after getting circumcised their partners could have sex longer before reaching orgasm. Some of the clinic nurses reported that women would use metaphors such as, “He used to go from here [Mbabane] to Manzini [a city half an hour’s drive away], now he can go all the way to the border.”

Source 123, “Sensation and sexual arousal in circumcised and uncircumcised men”, states:

It is possible that the uncircumcised penis is more sensitive due to the presence of additional sensory receptors on the prepuce and frenulum, but this cannot be compared with the absence of such structures in the circumcised penis.

They (unintentionally?) demonstrate as much in their footnote, if only they were interested in the issue. The conclusion is that (voluntary, adult) circumcision doesn’t damage sexual pleasure because it is the same or enhanced for nearly all men and their female partners. So? This dismisses the diminished sexual pleasure for those outside the “nearly all” group. Those individuals matter, and no one should expect them to be mollified because another male is happy with his circumcision.

This approach is also based on “heads I win, tails you lose”. Circumcision is the same or better, and men can have sex longer. What logical reason can we think of that might explain lasting longer? Maybe this is good, but sexual pleasure involves a degree of individual preference. Not all males (or females) will want or need sex to last longer to enjoy it to the maximum extent for themselves.

Ms. Banerjee endorses this flawed argument in her article:

Although tens of thousands of men who were circumcised as adults and were studied in several large-scale clinical trials (and in a Slate series) reported no loss—and in many cases an increase—in sexual pleasure and function, the intactivists claim that male circumcision is equivalent to female genital mutilation, a practice whose purpose is to constrain a woman’s sexuality and impair sexual function. In one of its worst forms, a pre-teen girl’s clitoris and entire external genitalia are cut, scraped, or burned out, which can cause severe pain, infection, life-long incontinence, obstructed labor and delivery, and even death. To be truly equivalent, one would have to cut off a man’s entire penis in order to produce the same effect, rather than a small flap of skin.

First, that Slate series was ridiculous. I refuted it here and here.

Second, the possibility that one person might not like being circumcised as a healthy child exposes the ethical problem that she fails to address. Male circumcision involves control, and can be intended to directly impair sexual function. (It definitively alters sexual function.) Most forms of FGM result in far more harm than a typical circumcision, but civil law recognizes no level of acceptable harm from non-therapeutic female genital cutting, including forms less harmful than male circumcision. One does not have to remove the entire penis to produce the same effect that is legally prohibited for female minors. Male circumcision is not acceptable because FGM is usually worse. Even if the foreskin should be viewed as a “small flap of skin”, it is the male’s small flap of skin. Self-ownership rights do not disappear because possible benefits exist from a non-therapeutic surgical intervention.

Where she challenges the appropriateness of the comments attached to Tinderbox’s Amazon page, Ms. Banerjee is correct. Where she expands that into an indictment of any position against circumcision, she stumbles. There is more to the application of science to healthy individuals, whether adults or minors, than just a limited subset of science and hard fact. No male’s healthy body is a platform for expressing another’s personal preferences and fears, whether those of parents or technocratic public health officials.

¹ Sampled on September 26, 2012, except for the rating on Ms. Banerjee’s review. I updated that today because I kept the link.

Flawed Circumcision Defense: Jesse Bering

“It requires education to see the world through disease-coloured glasses.” – Thomas Szasz (“Circumcision and the birth of the therapeutic state”)

Jesse Bering, PhD, endorses the AAP’s revised policy statement on non-therapeutic male child circumcision. He asks readers to replace the God he doesn’t believe in with the god he does believe in. He starts with some introduction about himself being circumcised, while his partner is intact. He then writes:

Whatever the reasons that previous generations may have had for choosing to remove their infant sons’ foreskins, they were almost always unconvincing. All else being equal – … – all else being equal, any dubious benefits derived from religious, social, hygienic, or aesthetic reasons are clearly outweighed by the costs of male circumcision. …

It might be surprising that I disagree with that. The costs clearly outweigh the benefits for me, then and now. But I do not believe that’s an objective conclusion for everyone. Each person has his own preferences unique to himself. It’s not for me to demand that anyone accept my opinion for myself as a substitute for his own opinion about his body. This involves the individual and his lack of need, and what those two details require for proxy consent.

Today, however, all is no longer equal, and the balance between the relative risks and benefits of male circumcision has clearly shifted in the other direction. That is, it has according to the American Academy of Pediatrics, which just earlier this week put out its revised position statement on infant male circumcision. Here’s the money quote:

Systematic evaluation of English-language peer-reviewed literature from 1995 through 2010 indicates that preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure. Benefits include significant reductions in the risk of urinary tract infection in the first year of life and, subsequently, in the risk of heterosexual acquisition of HIV and the transmission of other sexually transmitted infections.

There is no way for these relative inputs to clearly demonstrate the universal conclusion endorsed by either. The AAP and Bering demand too much. And the money quote is not what Bering provides, but instead this quote from the 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. …

As I wrote earlier, the highlighted statement is the ethical argument. It demonstrates the flaw in pretending that “preventive health benefits of elective circumcision of male newborns outweigh the risks” is an objective conclusion, or that it justifies proxy consent for non-therapeutic male child circumcision. The AAP Task Force stating its evaluation based on its members’ subjective weighting does not change the ethical and rights violation. Individuals – males, only – should not be forced to live with a permanent, non-therapeutic alteration to their bodies based on their parents’ subjective preferences.

… The more vocal “intactivists,” who’ve long been protesting what they regard as an antiquated, cruel and unnecessary ritual act against little boys that is just as abhorrent as female clitoridectomy, have also responded bitterly to this newest AAP development, seeing fresh strands in an ongoing web of conspiracy between the major health organizations, third-party insurance companies implementing the policy views of these organizations, and greedy practitioners who mislead parents about the benefits of circumcision only to reap insurance payouts for “mutilating” children’s genitals.

Even though there are instances of conspiracy thinking, which are inexcusable, this is a straw man. I quoted the key sentence from the AAP’s policy statement above. There are valid issues involved that do not require conspiracy thinking to reject the AAP’s recommendation. Erecting straw men doesn’t negate those issues. For example, bodily harm, physical integrity, self-determination, and equal protection. Something more than weak caricatures of opposing positions would be useful. Engage in an Ideological Turing Test, at least. That would be respectable, unlike “just watch the reactions to this little essay of mine”.

What is vital to understand about the AAP’s recommendation is that the Academy is not discounting, in any way, the biological purpose or function of foreskin. …

I can’t find anything in either the policy statement or the technical report that discusses the biological purpose or function of the foreskin in a manner suggesting someone might want it. I also won’t ignore the implication throughout that parents should be allowed to discount the foreskin in any way they wish for their son(s). That implication is a critical part of the analysis, since that’s where the AAP and Jesse Bering believe this non-therapeutic, unethical decision may be made.

Within the two columns of one page where the Task Force discusses the foreskin, it pursues only the question of whether sensitivity and/or function are altered. That is different than stating advantages of having a foreskin. The abstract merely states: “Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction.” Within those two columns in the Sexual Function and Penile Sexual Sensitivity section on page 769, the technical report is a bit stronger :

The literature review does not support the belief that male circumcision adversely affects penile sexual function or sensitivity, or sexual satisfaction, regardless of how these factors are defined.

The problem is that the literature doesn’t seem to support the belief that male circumcision does not adversely affect penile sexual function or sensitivity, either. (Circumcision always alters the mechanics of the penis.) From the two “good quality randomized controlled trials that evaluated the effect of adult circumcision on sexual satisfaction and sensitivity in Uganda and Kenya” since 1995, the reports were compelling. Except for the caveats:

… [The Ugandan] study included no measures of time to ejaculation or sensory changes on the penis. In the Kenyan study (which had a nearly identical design and similar results), 64% of circumcised men reported much greater penile sensitivity postcircumcision.127 At the 2-year followup, 55% of circumcised men reported having an easier time reaching orgasm than they had precircumcision, although the findings did not reach statistical significance. The studies’ limitation is that the outcomes of interest were subjective, self-reported measures rather than objective measures.

It doesn’t bother me if a male is happy with being circumcised, even if his parents made his decision in childhood. That doesn’t change the ethical issue. I’m questioning the applicability of these studies on adults to newborns. Those limitations are critical. It’s also hardly compelling to imagine that individual preferences should be ignored in favor of population-based opinions. Within every finding in those two studies, there are males who do not conclude that circumcision is neutral or better for themselves.

From the Sexual Function section:

There is both good and fair evidence that sexual function is not adversely affected in circumcised men compared with uncircumcised men.131,134–136 …

Quoting the the study in footnote 136, “Sensation and sexual arousal in circumcised and uncircumcised men”:

It is possible that the uncircumcised penis is more sensitive due to the presence of additional sensory receptors on the prepuce and frenulum, but this cannot be compared with the absence of such structures in the circumcised penis.

Maybe that should’ve been included in the Sexual Satisfaction and Sensitivity section? To restate the obvious: the foreskin is removed during circumcision. Comparing that in circumcised men is impossible. Or, as the technical report states:

Limitations to consider with respect to this issue include the timing of IELT [intravaginal ejaculation latency time] studies after circumcision, because studies of sexual function at 12 weeks postcircumcision by using IELT measures may not accurately reflect sexual function at a later period. …

Studying whether or not adult circumcision adversely affects sexual sensitivity or function does not necessarily answer the same question for males circumcised as infants.

Back to Bering’s post:

… What the task force has implied, rather, is that whatever the advantages to being an intact male – such as increased sensitivity of the glans, protection, lubrication facilitating better heterosexual intercourse (in addition to the lubricating properties of shed skin cells and oils that accumulate under foreskins, an accentuated coronal ridge may also retract more vaginal fluids during copulative thrusting) – these advantages are overshadowed in importance by the prophylactic benefits of removing highly receptive HIV target cells that are found on the inner mucosal surface of the foreskin. …

Did the Task Force consider any of the advantages Bering listed? I didn’t see any of them stated in the policy statement. That suggests to me that the Task Force discounted the foreskin. They don’t appear to have considered the foreskin in any meaningful way. The recommendation that the benefits outweigh the risks is subjective and lacking in universal applicability. They proved no overshadowing.

To quote Task Force member Douglas Diekema, male circumcision “does have medical benefit. Not everyone would trade that foreskin for that medical benefit.” That seems obvious, especially since it’s implied in the ethical issues section of the technical report. That’s what makes it odd to see the nonsensical declaration in the abstract. And from Bering:

To circumcise, or not to circumcise? To me, at least, that’s no longer even a question. It remains as much a no-brainer as it was when I first wrote about this issue two years ago. If male circumcision reduces the probability of contracting the HIV virus even a fraction of a percent—let alone the estimated 60 percent reduction that scientists believe it does—…

From the technical report:

Mathematical modeling by the CDC shows that, taking an average efficacy of 60% from the African trials, and assuming the protective effect of circumcision applies only to heterosexually acquired HIV, there would be a 15.7% reduction in lifetime HIV risk for all males.

I’m aware of no studies showing a reduced risk from circumcision for anything other than female-to-male transmission through vaginal intercourse, so that assumption is perhaps reasonable. (The difference in context between the U.S. and the high epidemic in Africa may reduce the number further.) Thus, the 60 percent relative risk is not the correct number. The estimated 15.7% lifetime relative risk reduction becomes a fraction of a percent reduction in absolute risk of heterosexually acquired HIV in the United States.

… then why on earth wouldn’t you choose circumcision? …

Because the healthy child does not need and may not want to be circumcised? Because he still has to wear a condom? Because there are risks and costs from circumcision? Because not everyone would trade that foreskin for that medical benefit? Because all individual tastes and preferences are unique? That’s why on earth parents shouldn’t choose circumcision for their healthy sons.

In the context of the quote that opens this post:

… Have you ever seen a person slowly succumb to AIDS? The pain inherent therein is not even in the same galaxy of subjective experience as whatever minute qualia of pleasure may or may not be lost to such a “mutilation.” The sacrifice is no longer one made to a mythological deity, but to the child himself. HIV is not just an African problem, the logistics apply to any part of the world where the virus is found, …

Do we know the subjective experience difference is a minute qualia of pleasure? Does the child want that sacrifice made to him? He doesn’t need it and has ways to achieve the same benefit in greater measure.

… and circumcision protects against more than this one virus alone. If you want to invest in the probability that your son will grow up to become so unfailingly logical that lust will never, not even once, overcome his level-headedness, and that he will always have both a condom on hand and use it every single time that an opportunity to have intercourse with a potentially infected stranger arises, that’s your prerogative. You’ve probably not interacted with many actual human beings in your life, but, hey, it’s your kid.

I am so unfailingly logical that lust has never, not even once, overcome my level-headedness. I do not want or need that benefit in exchange for my foreskin, yet I no longer have my choice about my body. But, hey, I’m my parents’ kid. My foreskin belonged to them, so why I should I reject their decision about my body?

One can either listen to …, the overwrought intactivists attempting to intimidate new parents through strong rhetoric and graphic images of botched circumcisions, …

What does “Have you ever seen a person slowly succumb to AIDS?” qualify as, if not strong rhetoric?

What was once unquestionably “inhumane” and “unethical” has, oddly enough, made a complete about-face as a consequence of vitally important scientific data emerging over the brief span of two highly productive decades. Yet many parents continue to be emotionally sabotaged by the baby-harming language of intactivists and online blowhards, whose rhetoric primes them to either see these critical developments in conspiratorial terms or to indulge in amateurish debunking of complicated research.

Debunk? I’m not trying to do that. I accept the reality of every potential benefit, without relevant caveats. If nothing else, it’s because I don’t need them. It’s all in the truth that not everyone’s cost-benefit analysis will reach the same conclusion. Parents aren’t psychic for what their sons will want.

But I can read the policy statement abstract, the technical report, and its sources to understand where they don’t quite mesh. They don’t support the sweeping, conclusive statements the AAP makes that Bering endorses.

So here’s one of those rhetorical devices that intactivists should appreciate: Cut it out. For every amazing prepuce you save, you’re adding an element of risk and uncertainty for the person attached to it. Nobody can possibly know what viral foes a man will come up against in his life, and if one of them is HIV, your crusade, admirable though you feel it is, may be costing some other parent their child’s life.

Every circumcision adds an element of risk and uncertainty for the person attached to the foreskin. Nobody can possibly know what viral foes a man will come up against in his life, including his parents. If one of them is HIV, he should be wearing a condom. (And maybe consent to voluntary circumcision as an adult, if he’s inclined.) If he becomes infected, the responsibility rests with him, not me. Not that HIV is automatically fatal anymore. It’s also worth considering the possibility that other solutions may be discovered in the future, and maybe before a child born today becomes sexually active.

The framing of costing a parent their child’s life is bizarre, as if parents own their children. Permitting (and encouraging) non-therapeutic male child circumcision treats parents as the owners of their son’s prepuce, which is odd from a human rights perspective, but also from the reality that parents are legally prohibited from acting as if they own their daughter’s prepuce.

AAP Circumcision Policy – Flawed Ethics

Much has already been said on the flaws in the AAP’s revised policy statement on non-therapeutic male child circumcision. (Here’s an additional plug for the exceptional rebuttal by Brian D. Earp.) I want to comment directly on its recommendations and the ethical issues addressed – or unaddressed – in the technical report. First, from page 757:

The Task Force made the following recommendations:

  • Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it.
  • …
  • Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.

These two statements conflict. Stating that the benefits outweigh the risks is a judgment call based on subjective valuations of the various inputs. The task force recognizes this when acknowledging that some parents would value other considerations more than the AAP’s evaluation of the net effect. That same possible difference of opinion applies to the cost-benefit analysis itself, which should include actual costs (i.e. the foreskin) rather than just risks.

The AAP is stating that it’s possible to disagree with the task force, but only to an extent because it reviewed the data and drew a conclusion. That’s wrong because the evaluation requires subjective weightings rather than objective criteria. It’s one thing to question the possible benefits altogether, as some do. It’s also possible to accept the potential benefits while not valuing them more than the costs involved. All individual tastes and preferences are unique. AAP Circumcision Task Force member Dr. Douglas Diekema said as much prior to the release of the revised policy statement. Why is that not reflected here in place of this incorrect statement that the benefits definitively outweigh the risks (and the unmentioned costs/harms)?

Further discrediting its recommendation on this, the ethics section (Pg. 759) states:

… 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 highlighted statement is the ethical argument. This accurate statement contradicts the conclusion the AAP presents that the potential benefits definitively outweigh the risks it considered. It is more relevant in the context of what the individual being circumcised might value. How will he – rather than his parents – want the benefits, risks, and costs weighed against each other for his normal, healthy foreskin? That’s the ethical core that the AAP Task Force sidestepped. Its recommendation for proxy consent for non-therapeutic circumcision is indefensible.

Moving on to the Ethical Issues section (pp. 758-760):

As a general rule, minors in the United States are not considered competent to provide legally binding consent regarding their health care, and parents or guardians are empowered to make health care decisions on their behalf.9 In most situations, parents are granted wide latitude in terms of the decisions they make on behalf of their children, and the law has respected those decisions except where they are clearly contrary to the best interests of the child or place the child’s health, well-being, or life at significant risk of serious harm.10

Sure. But that doesn’t support non-therapeutic male child circumcision. Proxy consent for permanent, amputative surgery must require something approaching objective need. Legally, we already require this for non-therapeutic genital cutting on female minors, including that which is analogous to or less harmful than a typical male circumcision. The comparison to be made for non-therapeutic male circumcision is whether or not parents are given this same non-therapeutic, cultural latitude in cutting the genitals of their daughters. They are not, which demonstrates that it shouldn’t be about the parents but about the child.

(a) Except as provided in subsection (b), whoever knowingly circumcises, excises, or infibulates the whole or any part of the labia majora or labia minora or clitoris of another person who has not attained the age of 18 years …

Subsection (b) establishes that only therapeutic genital cutting is legal for female minors. Subsection (c) rejects all parental preferences, whether cultural or religious, for non-therapeutic genital cutting on their daughters. It’s improper for the AAP Task Force to treat non-therapeutic male child circumcision as if it’s just a health care decision. It’s unlike any other decision we allow. If nothing else, circumcision guarantees (i.e. “significant risk”) the child’s normal, healthy foreskin will be removed forever (i.e. “serious harm”). Do male minors ever become reasonable people who may disagree about the weighting of the benefits and risks?

Revisiting “reasonable people may disagree”:

Parents and physicians each have an ethical duty to the child to attempt to secure the child’s best interest and well-being.11 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. This situation is further complicated by the fact that there are social, cultural, religious, and familial benefits and harms to be considered as well.12 It is reasonable to take these nonmedical benefits and harms for an individual into consideration when making a decision about circumcision.13

It is not reasonable. The individual who must live with the permanent consequences of the decision, if the decision is to circumcise, is not the person taking these non-medical benefits and harms into consideration. (Here, based on my earlier excerpt from this paragraph, benefits such as a reduced risk of heterosexually-acquired HIV should be evaluated as non-medical because they are a non-therapeutic justification for surgical intervention via proxy consent. Or remedy my rebuttal to “these medical benefits, non-medical benefits, and harms” if my precision focused on the lack of need irritates.)

In footnote 13, which is Diekema’s “ethics” perspective on Boldt v. Boldt, he concludes:

(3) Absent a significant medical indication, circumcision should not be performed on older children and adolescents in the face of dissent or less than enthusiastic assent.

This is important. Infants can’t consent, of course, but there is no reason that an inability to consent should be construed as a “yes” in favor of his parents’ preferences. Not even benefits that reasonable people may determine do not outweigh the risks (and costs). From the Ethical Issues section of the policy statement technical report:

Parents may wish to consider whether the benefits of the procedure can be attained in equal measure if the procedure is delayed until the child is of sufficient age to provide his own informed consent. These interests include the medical benefits; the cultural and religious implications of being circumcised; and the fact that the procedure has the least surgical risk and the greatest accumulated health benefits if performed during the newborn period. Newborn males who are not circumcised at birth are much less likely to elect circumcision in adolescence or early adulthood. Parents who are considering deferring circumcision should be explicitly informed that circumcision performed later in life has increased risks and costs. Furthermore, deferral of the procedure also requires longer healing time than if performed during the newborn period and requires sexual abstinence during healing. Those who are already sexually active by the time they have the procedure lose some opportunities for the protective benefit against sexually transmitted infection (STI) acquisition, including HIV; moreover, there is the risk of acquiring an STI if the individual is sexually active during the healing process. (See the section entitled Sexually Transmitted Diseases, Including HIV.)

First, note that it references a section on STDs, including HIV. Condoms are a cheaper, ethical way of achieving the same benefits and in greater than equal measure. They’re also still necessary after circumcision to prevent STDs, including heterosexually-acquired HIV. Yet, the word condom appears¹ zero times in the body of the technical report. Why?

The same applies to the other benefits, or there are safe, effective, non-invasive treatments available. It’s also reasonable to infer that, since people may disagree based on their preferences for whether the benefits outweigh the risks, people may also differ on whether the cited gains from infant circumcision rather than voluntary, adult circumcision are worth the trade-offs of their foreskin and their choice. The “greatest accumulated health benefits” isn’t enough to justify circumcising the individual who will not want to be circumcised.

The most crucial sentence in that excerpt is the third. Males left with their normal genitals are less likely to elect (or need) circumcision. This is too often portrayed as something akin to weakness or cowardice in the autonomous male, for which parents can be the brave, responsible decision-maker. (e.g. Brian Morris et al.) That’s a bad framing device. Instead, this unwillingness (i.e. less likely) is the most powerful indicator that males left with their foreskin value something more than being circumcised. Even if that is merely a desire to avoid the (perceived) pain of the surgery, it is proof of their preference against being circumcised. It is not better to guarantee that pain by forcing it on them in infancy. The typical defense is that they won’t remember it, which is so ridiculous that it could justify any intervention. As AAP Task Force member and bioethicist Douglas Diekema said, “Not everyone would trade that foreskin for that medical benefit.” If the AAP had reflected that view in its recommendations, the revised policy statement could’ve been ethical.

For the remaining sentences, parents who are considering deferring circumcision should be explicitly informed that circumcision performed later in life has a very low likelihood of being necessary. Why leave this point out to focus only on one side of the equation if parents should be fully informed? It shouldn’t be included as an abused throwaway in a technical report most parents will never know exists.

In cases such as the decision to perform a circumcision in the newborn period (where there is reasonable disagreement about the balance between medical benefits and harms, where there are nonmedical benefits and harms that can result from a decision on whether to perform the procedure, and where the procedure is not essential to the child’s immediate well-being), the parents should determine what is in the best interest of the child. In the pluralistic society of the United States, where parents are afforded wide authority for determining what constitutes appropriate child-rearing and child welfare, it is legitimate for the parents to take into account their own cultural, religious, and ethnic traditions, in addition to medical factors, when making this choice.11

It is not legitimate. The Task Force’s own words demonstrate that it’s possible for the individual male to not value circumcision. He is in his parents’ care for 18 years. (Per Diekema’s recommendation, his parents may be able to choose non-therapeutic circumcision for only a few of those years.) He will then be an autonomous adult for what will likely be another 40 to 80 years. What will he believe is in his best interest about his normal body for that time period? If his parents circumcise him, he will never be autonomous on this question. (As his sister(s) will be by law, contra the absurd idea that parents should be afforded wide authority to determine what constitutes his best interest forever.)

This decision involves informed proxy consent, not informed consent. For this, non-therapeutic circumcision, there is no reasonable disagreement about the lack of need. What is in the child’s best interest is to not undergo unnecessary surgery for reasons he may not value. He can choose it later, or his parents can choose it should genuine medical need arise while he remains their responsibility. He can’t unchoose it once it’s imposed.

The technical report does not support the AAP’s recommendations because it contains omissions and contradictions. Both the technical report and the condensed versions are irresponsible documentd that will perpetuate the violation of the bodies and rights of newborn males. They should be retracted.

¹ It appears once in a footnote as part of the title of a source.