Category: Media Marketing

Progress in The New York Times

The New York Times has a story on prohibitions in Southern California.

Once known for its sunny, freewheeling disposition — a live-and-let-live sensibility rooted in Western ideals and relied upon by generations of surfer dudes and misbehaving Hollywood stars — this region has long been as regulated as anywhere. Lately, however, cities, school districts and even libraries have been outlawing chunks of what used to pass here for birthright at a startling clip.

Most of the examples rightly appear as silly and intrusive, but I’m not focusing on that or the various political aspects involved. Instead, the proposed prohibition on non-therapeutic child circumcision in Santa Monica gets its inevitable mention. Brace yourselves.

A ban on circumcision (“male genital mutilation”) was registered for the Santa Monica ballot last year, then dropped in an ensuing uproar — but not before state legislators got to work on a law banning circumcision bans. It was passed and signed by Gov. Jerry Brown in October. …

That is unbelievable. I expected a mention of the Santa Monica proposal when I read the article. I didn’t expect this treatment. Everything in there is simple fact without further speculations or defenses in favor of circumcision. A prohibition on non-therapeutic child circumcision is not like the others because it’s neither innocuous nor reasonable within a proper understanding of individual freedom. The only birthright is genital integrity. However, the only information that could be questioned is the one piece of information that tells the truth in an unsettling way. Yes, male genital mutilation had quotes, but I still consider that a sign of progress. Remember that prior New York Times reporting on male circumcision hasn’t been quite as rigorous in dealing with facts or relying on credible sources. This is minor but promising.

The AAP Worsens Its Flawed Circumcision Position

A lot has already been said about the AAP’s revised policy statement on non-therapeutic circumcision on non-consenting male children.

More will be said today and beyond. Much of it will be uncritical regurgitations of the AAP’s revision by news organizations. There will also be analysis from those who recognize and highlight the glaring deficincies and oversights in the policy. I expect to contribute my own thoughts. For now, I’ll highlight one key aspect from my initial read-through before going into what I think is a more important consideration to this apparent-but-not-really temporary setback.

The short version of the statement ends with this (emphasis added):

Parents ultimately should decide whether circumcision is in the best interests of their male child. They will need to weigh medical information in the context of their own religious, ethical, and cultural beliefs and practices. The medical benefits alone may not outweigh these other considerations for individual families.

That’s so close to the ethical stance. Remove families and focus on the individual and it would be ethical¹.

The way the promoted portion of the new “finding” within the revised statement differs from this conclusion is the key takeaway to challenge the supposed change from the AAP, which is really more-or-less just an exercise in urging politicians to permit circumcision on Medicaid. Here, the AAP demonstrates that its evaluation of the net benefit, that possible benefits outweigh the risks, is subjective and determined only by individuals. This directly contradicts the supposed proof based on their review of research that the potential benefits outweigh the risks (and the costs – the direct harm in every case – that they ignore). We should repeatedly emphasize that as often as necessary.

My concern is that we’ll get stuck in this low-level, short-term portion of the larger debate. It’s clear from European medical associations and courts that the eventual destination is public policy against non-therapeutic circumcision. The AAP and American society, in general, are (inexcusably) behind. But both will get there. Activists for the rights of children can make that happen sooner than it otherwise might happen.

The key is that we must give people the opportunity to save face, to avoid digging in to protect their egos. The problem is their stance, not necessarily their character. It should be obvious to them that their stance is incorrect. It isn’t. To address that, do we want to express an irrelevant, limited sense of superiority or convince others that we’re correct because facts and ethics demonstrate the case we’re making? If we impugn their motives and/or character by choosing the former, we may extend the period during which this policy statement stands or encourage people who can be influenced either way to choose the inferior stance of the AAP.

Edit note: I changed “it’s” to “their stance” to avoid possible confusion.

¹ The existing societal view treats certain basic human rights – for boys only – as a buffet from which parents may pick and choose for their own reasons. This is the problem merely expressed within the AAP’s policy statement.

Flawed Circumcision Defense: Yair Rosenberg, Part 2

In response to the AAP’s pending release of its revised policy statement on non-therapeutic male child circumcision, Yair Rosenberg repeats the mistakes in his prior analysis. He perpetuates appeals to authority, omits relevant information, and ignores inconvenient facts. One might even say he’s being obscurantist.

This isn’t just an issue of religious freedom—it’s a basic question of public health. That’s because according to the National Institutes of Health and the World Health Organization, among others, circumcision is one of the global health community’s best HIV prevention techniques. As Eric Goosby, the U.S. AIDS coordinator, has said, “Male circumcision is a highly significant, lifetime intervention. It is the gift that keeps on giving. It makes sense to put extraordinary resources into it.” To that end, anti-AIDS organizations are partnering to circumcise 20 million African men by 2015. …

Until now, the scientific consensus surrounding circumcision has driven policy in Africa, but not the United States. Today, that changes.

Individual humans make up “public health”. What is – and is not – acceptable to do to individual bodies in the name of public health is the question of ethics that Rosenberg, Goosby, the AAP, and every other circumcision advocate ignores. This is especially true because circumcision is not the least invasive or the most effective method available for reducing HIV (or any other) risk. It’s also still not particularly useful in contexts outside of parts of Africa. As I wrote in my prior post, the risk reduction is in female-to-male HIV transmission in high-risk populations. That isn’t compelling within the scope of the AAP’s focus. Context matters. Obscurantist journalists ignore that.

The importance of this [updated policy] cannot be overstated. …

It can be. Rosenberg’s post is proof.

… The AAP is a driving force behind health policy in America, and the experts involved in its new statement are already going on record in major media outlets to advocate that circumcision be covered on public health plans like Medicaid. The statement solidifies the scientific consensus behind the advisability of infant male circumcision (noting that complications are more likely to arise when the procedure is performed later in life) and places the traditional practice squarely within the realm of sound medical science.

This is only true if ethical considerations are not a part of sound medical science. It’s fine if Rosenberg or others do not wish for ethics to be applied to their own bodies. But not everyone shares that odd, limited view. Some of us appreciate the basic concept of human rights, including those of physical integrity and self-determination, and wish they had been applied to us. It’s too late for too many males, but there is never a bad time to stop violating human rights.

Also, the question of possible benefits and their applicability to any particular individual is separate from the public policy question of paying for non-therapeutic surgical interventions on non-consenting individuals. Non-therapeutic infant circumcision is an irresponsible use of funds in pursuit of subjective goals via unethical means. There is nothing good about it, regardless of how “prestigious” an organization promoting the idea is irrationally perceived to be. An organization that advocates violating human rights deserves no prestige.

This is not just good news for the United States, where obscurantist anti-circumcision groups have sought to completely ban this medically beneficial practice rather than allow families to choose whether to perform it. …

Rosenberg’s prior essay was obscurantist propaganda. Unlike his writing, I’ve acknowledged the arguments offered in favor of circumcision. I’ve explained why they’re inferior in the debate as it pertains to individuals. Mr. Rosenberg has not done the same. Instead, he offers condescending evasions:

… It’s also a powerful rebuttal to the flawed reasoning of the German court in Cologne, which ruled that circumcision generally constitutes “bodily harm,” yet made allowances for circumcisions performed for “medical reasons.” Thanks to the AAP, we can now state that all circumcisions are medically beneficial. …

The German court in Cologne ruled that non-therapeutic circumcision on non-consenting children violates their rights to physical integrity and self-determination. There is no flaw in that expression of basic human rights. The are the same rights that form the basis for prohibitions on FGC/M.

The court’s finding that circumcision constitutes bodily harm, no quotes, is consistent with permitting circumcision for medical need. The existence of a problem necessitates considering interventions. Ethically proxy consent will choose the least invasive, most effective solution. That is rarely circumcision when there is a need. But where it is necessary, the goal is an objective net benefit, that the surgery will remedy the problem. The outcome is presumed to outweigh the harm imposed to achieve it. The key is the outcome can be measured immediately and directly. Is the malady resolved?

With non-therapeutic circumcision, there is no objective net benefit because there is no malady. There is only objective harm for subjective benefits. The subjective benefits may not be valued or desired by the individual. In that case it’s objective harm to the individual for the subjective preferences of another. That is unethical. Because surgery on children involves proxy consent, medical need is required. The court was correct and consistent. The AAP is incorrect and encouraging unethical rights violations.

So, can we really state that all circumcisions are medically beneficial? Including the ones where the boy suffers a complication? If he loses his glans, is he still benefited? What about his entire penis? What about the thankfully rare instances where the boy loses his life? At least the benefits accrued over his short lifetime? Since all of these scenarios happen, even if we ignore my focus on individuals who suffer only the expected harm, isn’t it a bit obscurantist to state that all circumcisions are medically beneficial?

… If German courts continue to prosecute Jews and Muslims for practicing circumcision, then we will know that this animus is rooted not in science or fact, but in ignorance and prejudice.

I won’t say I expected his screed to end with something other than a preemptive ad hominem attack. It’s still pathetic.

Update: Walter Russell Mead uncritically endorses Rosenberg’s flawed post and makes a request:

Hopefully anti-circumcision zealots will take a deep breath and rethink their fevered stance on the issue. Beyond the fact that their bans impinge on the rights of Jews and Muslims to practice their religion as they see fit, they ought to consider that there is legitimate science pointing to the practice being beneficial to infant male health.

The only legitimate science involving infants is on UTIs, and possibly penile cancer. The former are uncommon in intact males in the first year (1%) and almost always easily treatable. The latter is more reasonably associated with other causes, with U.S. rates similar to those in mostly intact Europe. Everything else involves adult volunteers. The possibility of health benefits, or even religious benefits, does not render non-therapeutic circumcision on a child ethical.

No court in the United States endorses a right to practice one’s religion as members “see fit”. There are limits that may be imposed based on constitutional tests. Non-therapeutic child circumcision should fail that test because it is physical harm.

Flawed Circumcision Defense: Charlotte Allen

Charlotte Allen has an editorial in today’s Los Angeles Times about circumcision and intactivists. She doesn’t understand either. She begins:

The “intactivists” — anti-circumcision people who are trying to get the practice outlawed in the U.S. and elsewhere — …

This is off to a terrible start. The effort is to prohibit non-therapeutic circumcision on non-consenting individuals. That’s an ethically significant difference. While I suspect she thinks that her words mean what I just wrote, they don’t. Her claim is what’s being repeated, as if this effort is the same as seeking a complete prohibition on religious circumcision for everyone of any age. When arguing against something, the first requirement is to fairly and accurately state the opponent’s position. She fails at that in the first half-sentence.

Intactivism, a movement of the last 20 years or so, got a boost recently when a German judge ruled that non-therapeutic circumcision of children amounted to “bodily harm” and must henceforth be outlawed. …

First: intactivism in its current form has been going on for at least twice as long as she claims. (e.g. Van Lewis)

Re: the court’s ruling. The issue of bodily harm, which is objective, appears only here. She will not directly address this again. She mentions sensitivity, as though that’s the extent of possible harm, and draws an incorrect conclusion by selectively quoting a press release. (More on that in a moment.)

The tagline attached to Ms. Allen’s essay is this:

‘Intactivists’ are trying to get the practice outlawed in the U.S. and elsewhere. But how bad can it be?

There is bodily harm in every circumcision. But to the question, it can be very bad. This bad. Or this bad. Or the worst case scenario. Those are thankfully rare, but they occur. Those males are (or were) individuals with human rights. They are not merely statistics to ignore.

The intactivists like to paint circumcision in lurid colors. The phrase they use to describe it — “male genital mutilation” — evokes the barbaric practice of female genital mutilation. But the two have almost nothing in common. …

Mutilation is an accurate description for non-therapeutic male circumcision without the child’s consent. And it has considerably more in common with female genital mutilation than Allen understands.

She continues:

… Female genital mutilation is invasive and ghastly, and results in long-term health risks for women subjected to it, not to mention the diminution or elimination of the ability to feel sexual pleasure. …

Usually, yes, but that doesn’t justify male circumcision. As I’ve said elsewhere, a punch to the face is not acceptable because a knife to the gut is worse. The difference should be in punishment, not prohibition.

Apart from the valid aspects of the comparison of non-therapeutic genital cutting on a non-consenting individual, male or female, male circumcision is unethical on its own.

Male circumcision involves snipping off about three-eighths of an inch of skin. It hurts, briefly, but so do the shots that babies routinely receive. And according to the World Health Organization, it “reduces the risk of heterosexually acquired HIV infection in men by approximately 60%.”

That three-eighths of an inch of skin will grow into a larger structure if left in place. It also removes the nerve endings within that three-eighths of an inch, and leaves a scar. But with that argument, the clitoral hood, or even the clitoris, is a tiny structure in infants. Does that render it ethical to remove either of these from a healthy infant? She’s offering a ridiculous defense of non-therapeutic genital cutting on a non-consenting individual.

For the HIV statistic, she cites this page. She failed to quote pertinent information beyond the first sentence. She should’ve included the part that says “male circumcision should be considered an efficacious intervention for HIV prevention in countries and regions with heterosexual epidemics, high HIV and low male circumcision prevalence.” Not one of those three criteria matches a Western nation. It isn’t compelling. Citing it as a justification for infant circumcision is an empty defense, which is worsened by additional arguments against this reason for circumcising infants. (Anything other than circumcision with the voluntary consent of the individual where those scenarios apply is still unethical.)

The notion that circumcision reduces a man’s sexual sensitivity has little basis in fact. Two medical studies, in 2003 and 2007 — one presented to the American Urological Society and the other published in the Journal of Sexual Medicine — found that circumcised and uncircumcised men experienced the same levels of response to touch and pain during sexual arousal. A press release issued by the 2007 study’s chief researcher, at McGill University in Montreal, stated: “This study suggests that preconceptions of penile sensory differences between circumcised and uncircumcised men may be unfounded.”

Suggests is not a synonym for proves. Allen seems to possess a tendency to consider only what is convenient rather than presenting all facts. This press release from McGill University about that study includes the following caveat:

Payne cautioned that though the study’s results are very promising, they are still preliminary and do not necessarily resolve many of the longstanding controversies surrounding circumcision. “This study only measures one sensation, so it questions the held notions, but it does not refute the idea that there may be some differences at some level. No one can deny the anatomical differences between a circumcised and uncircumcised penis.”

To be fair, it’s possible that the version she read didn’t include that caveat. I’m not sure why a press release from these scientists wouldn’t include such a caveat, but I don’t know what her source is. However, a simple bit of thinking reveals the inherent flaw in drawing such a broad conclusion from research like this. This basic fact can be confirmed by reading the study itself:

… 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. …

To state the obvious: the foreskin is removed during circumcision. Comparing that in circumcised men is impossible. The study does not demonstrate what Allen claims it demonstrates.

It’s obvious that Allen has not considered anything beyond her limited understanding of circumcision. At best, she presents lazy thinking with minimal research. Or worse, she started with her conclusion and created a fortress around her mind to protect myths and block facts. Whatever the reason, she is wrong. Her defense of non-therapeutic circumcision on children is pathetic.

**********

Post Script: Unsurprisingly, more errors exist in Allen’s analysis. I included them in the original version of this post. I deleted them because they weren’t egregious in the way the above excerpts are. I’ll include one bit in the comments. The above is what I think should be the critical argument against her propaganda.

Fun With Headlines: Misstating Facts

Before addressing the story itself, consider how various news agencies are reporting on the ruling from the District Court of Cologne.

German court: Circumcision on Jewish boys assault (USA Today)

German court rules that circumcision is illegal (Haaretz)

German court: Circumcision on boys an assault (Boston.com)

German court rules religious circumcision of minors is ‘assault’ (Global Post)

The problem here is the challenge it presents. Many people will do nothing more than scan the headlines and form an opinion. That is dangerous when the headline is an inaccurate or incomplete summary of a story. Brevity is important, and a fundamental fact of headline writing. But clarity should not be sacrificed. The Global Post and the Boston.com headlines get closest to the truth. That is commendable.

Lawsuits as Strategy Follow-Up

In what will come as no surprise, a U.S. District Judge Karen Schreier dismissed the lawsuit Dean Cochrun filed over his circumcision. (Original post) This news article reported the dismissal, although I don’t believe the facts within the article are 100% accurate.

But U.S. District Judge Karen Schreier dismissed his case last week, finding that the federal court system has no jurisdiction over such a small claim. She also ordered him to pay a $350 filing fee.

Judge Schreier dismissed the case, finding that the court has no jurisdiction. As I read the decision, she dismissed it without regard to the sum, even though the sum Mr. Cochrun requested ($1,000) was less than the $75,000 threshold. Judge Schreier wrote:

… Because Cochrun has not alleged any facts to establish he and defendants are citizens of different states in support of diversity jurisdiction, his claim is subject to dismissal. See Barclay Square Properties v. Midwest Federal Sav. & Loan Ass’n of Minneapolis, 893 F.2d 968, 969 (8th Cir. 1990) (“When jurisdiction is based on diversity of citizenship, the pleadings, to establish diversity, must set forth with specificity the citizenship of the parties.”). Thus, the court need not consider whether his complaint has met the amount in controversy requirement. Because this court lacks subject matter jurisdiction, Cochrun has failed to state a claim upon which relief may be granted.

As always the caveat remains that I am not an attorney. It’s possible – probable, even – that I’ve misread or missed something. When Judge Schreier writes that “…Cochrun’s claims are dismissed without prejudice pursuant to 28 U.S.C. § 1915(e)(2)“, I assume it’s for (iii) rather than (i) or (ii). I could easily be wrong. But I read her decision as a dismissal based on lack of jurisdiction before considering any other questions involved. Mr. Cochrun filed a federal suit where all parties reside in one state. The court didn’t need to consider the relief sought. As I read it…

The point is that this was predictable and predicted. This is not a defeat. The challenge rests in how we promoted it and how much fiction opponents will read into the decision. For the former, anyone who jumped on this in our favor should probably reflect on the cost of blind support for anything that nominally might help us. For the latter, we need to confront it wherever we encounter it. Judge Schreier’s words are clear enough to prove that she did not rule on the merits of circumcision. The take-home is that this is neither evidence nor proof in favor of any conclusion regarding non-therapeutic male circumcision on a non-consenting minor. (Given the problems with Mr. Cochrun’s lawsuit and his plan to represent himself, I think we should be happy this was dismissed on lack of jurisdiction, as expected.)

Flawed Circumcision Defense: Mitchell Warren

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In its Uganda findings (page 55):

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

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

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

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

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

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

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

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

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

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

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

Lawsuits as Strategy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

On the second point, from the included link:

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

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

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

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

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

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

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

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

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

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

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

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

In the “Cosmetic Outcome” section, they write:

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

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

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

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

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

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

Further Thoughts on Dr. Diekema’s Recent Statements

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

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

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

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

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

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

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

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

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

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

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

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