Category: “Voluntary”

Examples of the Need to Reverse the Approach

Following on yesterday’s post, The Guardian posted four letters from readers about Catherine Bennett’s excellent essay against non-therapeutic male circumcision. Three of the letter-writers believe they’ve found a weakness in her argument. They’re mistaken, and in odd ways. (I’m omitting points that are mistaken but beyond the comparison.)

First:

Female genital circumcision implies the removal of the clitoris, sometimes with the inner labia, sometimes infibulation. It is often practised with blunt razors or knives and without anaesthetics. The risks: fatal haemorrhaging, cysts, urinary and vaginal infections, chronic pain, obstetrical complications.

This supports my last post. This writer didn’t figure out how the comparison might work. She assumed it doesn’t. She started with FGM and worked back to discredit it.

The larger question is the relevance of the remaining facts in that paragraph. If those didn’t happen, and FGM occurred in a clean hospital room, I don’t believe her objection to it would change. She’s arguing for a distinction that doesn’t matter to the initial ethical question or the fundamental comparison. (It only matters to individual practices, which is still important to understand and change.)

She continues:

… There is no evidence whatsoever to support the notion that it affects function, sensation or satisfaction.

It’s incorrect to claim that there is no evidence that circumcision affects function, when the form changes. There is more to function than the ability to orgasm and impregnate. On that crude basis, an argument could be made that FGM doesn’t change function. Just limit “function” to whatever begs the question. (The latter two are subjective to the individual, which is also on the ethical point.)

Next writer:

Catherine Bennett is incorrect in describing female genital mutilation (FGM) as the “equivalent” of circumcision. Granted, both procedures involve a surgical modification of the external genitals of a non-consenting child. Both are, in my view, unacceptable.

That’s the key comparison. I don’t understand why this bizarre tangent follows:

There are, however, great differences: female genital mutilation is illegal in the UK and in many other countries worldwide, including in Africa. Circumcision is lawful. So campaigners against circumcision need to get into dialogue with the Jewish and Muslim communities and press for a change in the law.

Of course. But how is that relevant? The legality of an action doesn’t speak to its validity. Here, numerous historical examples could disprove that “correlation equals causation” mistake. Ms. Bennett made no error in comparing the acts.

This writer provides another paragraph, but it’s more helpful to move on to the next writer:

With reference to Catherine Bennett’s polemic on male circumcision, she should give more attention to the WHO’s statement that male circumcision can be a positive boon in relation to sexual cleanliness. …

This comment demonstrates the idea that one’s own subjective view should somehow be everyone’s objective view. It’s the idea that anyone against circumcision simply hasn’t considered some aspect allegedly in favor of circumcision. If the opponent would just think of benefit X valued by someone else, it would all be clear.

It doesn’t work that way. Much of the debate is subjective to the individual affected. That’s a reason the choice belongs only to the male himself. Me, I prefer to bathe properly and engage in safe sex practices. The so-called “positive boon” to “sexual cleanliness” is irrelevant to me. Ethically, we’re left with the objective facts from a non-therapeutic surgery.

… That hidden space underneath the flap of foreskin is indeed a fertile breeding ground for bacteria and disease. …

That just as accurately describes female genitalia. I don’t imagine the letter-writer thinks that’s a ringing endorsement for female genital cutting.

… The German court’s ban on male circumcision has rightly been overturned by its parliament. …

They did not overturn the court’s decision. They passed a resolution showing support for circumcision as a parental choice. The resolution is essentially a promise to address the issue in the legislature in the fall. The letter-writer erred on a simple, verifiable fact.

… Babies and young children are not able to make rational decisions as to their welfare: their parents have to decide how they are fed; what names they shall be known by; what schools they will go to; to which religion they will be directed; all of which decisions have a significant effect on their later life. …

Parents make decisions for their children. Circumcision is a decision. Therefore, parents may circumcise their children. That’s flawed logic. It assumes that a decision is just merely based on parental choice. Surely the letter-writer sees the negative implications of that. One such implication would be that parents may also cut the genitals of their healthy daughters. The silliness of the argument is that parents may make many decisions, and they all apply to their children, except this one so-called parental right that only applies to their sons. If they make this decision for their daughters, we incarcerate them. It’s incomprehensible in a rational analysis.

… The only effect of male circumcision on their later life is enhanced cleanliness and hygiene.

Taking the statement at face value, because the male still has to bathe, the claim is rather silly. The only basis on which it works as support for non-therapeutic child circumcision is with the assumption that the male will not undertake the minimal additional effort to bathe himself properly if left with his normal foreskin. Without that (offensive) assumption, the choice must be left to the male to decide whether he values his foreskin or saving a tiny bit of effort in the shower.

The larger problem is that this posited benefit isn’t the only effect. The male loses a normal, functioning part of his anatomy. He loses his foreskin, and suffers the damage to the nerve endings that remain. He is left with a scar that he may not find aesthetically appealing. He is left without the mechanical gliding action of his foreskin, so sex becomes a matter of friction rather than pressure. That’s not a valid parental choice.

That Word Doesn’t Mean What Secretary Clinton Thinks It Means

October 1, 2015 update: I changed the word “condemnable” to “commendable” to reflect the intended meaning of a sentence. Additionally, the link to Secretary Clinton’s comments is now here.

The United States government encourages and funds circumcisions. It shouldn’t, of course, if we’re to adhere to the basic principles of human rights. (We don’t on this.) But it shouldn’t be promoted with lies. U.S. Secretary of State Hillary Clinton spoke yesterday at the 2012 International AIDS Conference. (emphasis added)

As of last fall, every agency in the United States Government involved in this effort is working together to get us on that path to an AIDS-free generation. We’re focusing on what we call combination prevention. Our strategy includes condoms, counseling and testing, and places special emphasis on three other interventions: treatment as prevention, voluntary medical [sic] male circumcision, and stopping the transmission of HIV from mothers to children.

Any familiarity with this subject provides a spoiler alert on what voluntary really means. Sure enough, shortly after that paragraph:

On male circumcision, we’ve supported more than 400,000 procedures since last December alone. And I’m pleased to announce that PEPFAR will provide an additional $40 million to support South Africa’s plans to provide voluntary [sic] medical [sic] circumcisions for almost half a million boys and men in the coming year. (Applause.) You know and we want the world to know that this procedure reduces the risk of female-to-male transmission by more than 60 percent and for the rest of the man’s life, so the impact can be phenomenal.

In Kenya and Tanzania, mothers asked for circumcision campaigns during school vacations so their teenage sons could participate. …

Voluntary circumcision requires the consent of the circumcised. Consent from anyone else for non-therapeutic circumcision is unethical.

And, no, it isn’t “medical” circumcision. It’s medicalized circumcision, which merely indicates that it’s performed in a modern, sterile operating theater. That is commendable in its limited focus, but it is not enough to render the non-therapeutic surgery ethical. Consent is also necessary. The perceived benefit of a reduced risk of female-to-male HIV transmission is a speculative pursuit and may not be necessary or desired by the individual.

Always Ignoring Voluntary and Adult

As always, when public health officials discuss voluntary, adult male circumcision, they never mean voluntary or adult. Never:

ZIMBABWE is planning to expand its circumcision campaign to include newly-born babies as part of the country’s fight against the spread of HIV and AIDS, a senior health ministry official has confirmed.

The ministry’s AIDS and TB unit co-ordinator, Getrude Ncube, said a pilot project targeting babies between one and 28 days old would be launched before year end with the full programme likely to be rolled out in 2014.

They dress it up in nonsense.

“Although circumcising neonates will not have an immediate an impact, results will show in 20 years’ time. Our sole aim is to try and reduce new HIV infections.”

No, the sole aim is to implement circumcision. They believe their intentions are noble, a fact I do not doubt. But if their sole aim is to try to reduce new infections, they’d focus limited medical resources on those currently at risk of sexual transmission. They’re not, unless we stupidly assume all males aged 15 to 49 in Zimbabwe have been circumcised. Instead, they’re shifting to males who can’t consent. They still have 500,000 males to circumcise before 2015 to reach their target. The target is what matters, not the individuals being targeted.

Reading the Cologne Court’s Words

Since the recent ruling against non-therapeutic child circumcision by the Cologne district court, many have spoken out against it and claimed various and potentially extreme results that will flow from it. Some of these complaints are legitimate. As I previously wrote, there are issues offered by proponents of ritual child circumcision that deserve to be taken seriously. Asking people to let go of something they intensely value is asking them to bear costs, even if it should be clear that avoiding objective harm to the child must be stressed more. (That post is coming.)

Still, what I haven’t seen yet is the opposite view. I haven’t seen a single example of someone who supports legally-protected ritual child circumcision accurately acknowledge the court’s ruling as it was written, rather than using a selective reading, to defend the practice. (If someone has seen an example of a proper acknowledgement, please link it in the comments.) The closest I’ve seen comes from Chief Rabbi Lord Sacks, but he only built and defeated a straw man. Near his conclusion, he wrote:

That is what the court in Cologne has done. It has declared that circumcision is an assault on the rights of the child since it is performed without his consent. It ignored the fact that if this is true, teaching children to speak German, sending them to school and vaccinating them against illness are all assaults against the rights of the child since they are done without consent. The court’s judgement was tendentious, foolish and has set a dangerous precedent.

The issue of consent is only part of the court’s ruling. The child’s lack of consent factored because of what was being done to him. The court evaluated the act first. From an English translation of the ruling, found here:

… since the parents’ right to religious upbringing of their children, when weighed against the right of the child to physical integrity and to self-determination, has no priority, and consequently their consent to the circumcision conflicts with the child’s best interests. …

Circumcision violates the child’s (right to) physical integrity. Consequently, parental consent conflicts with the child’s rights, including his right to consent or to refuse. Contrary to Chief Rabbi Lord Sacks’ statement, the court did not imply parenting is now illegal. It made the necessary distinction to limit the ruling to non-therapeutic child circumcision.

… There was consent by the parents, but this was not capable of justifying the commission of the elements of bodily harm.

And:

… The parents’ fundamental rights under Article 4 (1), 6 (2) of the Basic Law (Grundgesetz, GG) in turn are limited by the fundamental right of the child to physical integrity and self-determination under Article 2 (1) and (2) sentence 1 GG. …

There are two rights involved. The right to physical integrity and the right to self-determination (i.e. consent). A complete attempt at a rebuttal requires acknowledging both.

An insufficient response such as that by Chief Rabbi Lord Sacks is not unique. Consider:

Muslim leaders joined the Jewish groups in their condemnation of the ruling. Ali Demir, chairman of the Islamic Religious Community in Germany, described circumcision as “a harmless procedure that has thousands of years of tradition and a high symbolic value.

There are also Christian (and probably secular) advocates who mistakenly defend circumcision as a parental right based on, but not limited to, their religious freedom. However, they all ignore, minimize, or fail to understand that circumcision, like all surgery, is not physically harmless to the child.

As the court stated, “the child’s body is permanently and irreparably changed by the circumcision.” Harm and its link to consent are the issues. Circumcision¹ inflicts harm, despite the presumed good intentions of parents. Only the individual directly affected can evaluate whether or not this objective physical harm is good, bad, or neutral for himself, permanently. Only he can decide whether or not he consents to this intrusion on his physical integrity. That is what the court ruled, not the convenient straw men floating around as a defense against the equal rights of children.

¹ Here I refer only to ritual and non-ritual non-therapeutic circumcision. Proxy consent for therapeutic circumcision requires further analysis and can be justified, although it also inflicts harm.

Strong and Non-Conflicting Evidence

A few days ago in the Huffington Post Canada, Sheryl Saperia defended non-therapeutic male child circumcision against the German court ruling. The title of her essay is “Male Circumcision is Not Mutilation, Period.” She is wrong.

After a bit of setup, she states:

For instance, neither the right to security of the person nor to gender equality should operate in such a way as to proscribe male circumcision on the grounds that it is comparable to the justifiably prohibited custom of female genital mutilation (FGM).

The two are ethically comparable. They are both non-therapeutic genital cutting on a non-consenting individual. That’s the comparison. It applies to every scenario.

But ignore the comparison. She’s jumping to the “FGM is worse, so male circumcision is okay” defense. Truncate her statement to the minimum necessary facts to understand male circumcision and the content of the ruling. Do male infants have the right to security of person? Assuming she answers correctly, that males possess this right, then non-therapeutic circumcision violates that. It is surgery, and without the recipient’s consent. It inflicts harm. Sometimes that harm is greater than what is expected, and in thankfully-rare instances, it can be fatally so. But it always involves harm. The right to be secure in one’s person should include protection from unnecessary, unwanted harm for all children.

She continues:

FGM is sometimes termed female circumcision, but this is a misnomer as it implies a minor operation equivalent to male circumcision. According to Doriane Coleman, a Duke University law professor whose expertise is children and the law, “This analogy can and has been rejected as specious and disingenuous, as the traditional forms of FGM are as different from male circumcision in terms of procedure, physical ramifications, and motivation as ear piercing is to a penilectomy.”

The term female circumcision is a misnomer for semantic reasons, but also because, as she indicates, it fails to fully explain what FGM does. However, semantic accuracy of male circumcision does not prove that male circumcision cannot also be mutilation. Saying it’s not FGM isn’t enough.

Contrary to Professor Coleman, the analogy is neither specious nor disingenuous. It is not based on merely the traditional forms. The traditional form of FGM differs across cultures. The question of which version we should use exposes the flaw in the tradition approach. The varying extent of damage can be reflected in the codified punishment for violations.

It makes more sense to start with the principle involved. Again, non-therapeutic genital cutting on a non-consenting individual is wrong. The principle does not require equivalent damage for both to violate the principle. Anyway, the anatomical analogy to mnale circumcision is a hoodectomy. The latter is illegal, which brings in the topic of equal rights. The law does not protect the rights of male minors that it protects for female minors.

The motivations aren’t as different as suggested, either.

Next:

The World Health Organization is also clear that:

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

I prefer my fact sheet because it deals with principles and equality rather than outcomes. Still, even on the appeal to authority she begins here, she’s wrong. Within its fact sheet, WHO states:

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

To repeat myself, would WHO rebrand female genital mutilation to “female genital cutting” and declare it an acceptable parental choice if some health benefits were found? I find the possibility doubtful, at best. So why shouldn’t we also apply the basic logic of harm as “removing and damaging healthy and normal genital tissue, and interferes with the natural functions of bodies” to males? It’s okay to do this without their consent because we’ve pursued a “health benefits” justification for enough years, even though almost every claimed benefit can be achieved with less invasive preventions and/or treatments?

Ms. Saperia quotes a 1997 joint statement from several groups declaring “FGM to be universally unacceptable, as it is an infringement on the physical and psychosexual integrity of women and girls and is a form of violence against them.” Even if we pretend that there is no psychosexual violation to males, there is the clear infringement on their physical integrity. (She returns to this point later, although she furthers her error.) Circumcision is a form of violence against males. It inflicts some level of harm in every instance.

Instead of acknowledging this connection, she quotes the WHO to push the irrelevant facts about circumcision being a long-standing practice and that many reasons exist for its imposition on healthy children. And then the predictable argument about HIV, which is easily refuted, and also countered with the truth that condoms are still necessary after circumcision.

She proceeds into the illogical “no real harm”:

In the absence of strong and non-conflicting medical evidence that male circumcision regularly causes substantial harm to young boys, the arguments against the procedure are severely weakened. …

Substantial is a subjective word. What one person finds substantial, I might not. And vice versa. The core question is whether or not there is non-conflicting medical evidence that non-therapeutic male circumcision causes harm. There is. It causes harm, in every case. Normal, healthy tissue is removed. Nerve endings are severed. The resulting scar provides further proof, and the mechanical functioning is altered. I accept that many people think this trade-off is acceptable for the possible benefits. But only the individual male is qualified to make that evaluation for himself.

… Since male circumcision and FGM are simply incomparable, gender equality should not demand the banning of the former just because the latter is illegal. [ed. note: Again, they’re comparable in principle (and to an extent within FGM Type IV). The law should reflect that.] And while the right to security of the person is certainly implicated by circumcision, the low risk of harm (and the fact that most complications are extremely minor) means that this right should be balanced against other compelling rights, such as religious freedom.

There is not a “low risk of harm”. There is a 100% risk of harm. There is a low risk of complications, of unexpected outcomes. Those harms are not the same. There is no implication. The guaranteed harm of non-therapeutic circumcision violates the child’s right to security. That should be balanced against competing rights, but as the court found, a child’s right to physical security outweighs his parents’ supposed right to practice their religion. From an individual rights perspective, the parents’ religious freedom ends where the child’s body begins. The child also possess a right to religious freedom.

After a paragraph praising the unity the three major religions are showing in their criticism, she writes:

According to the German court, the right to religious freedom “would not be unduly impaired” because the child could later decide for himself whether to have the circumcision. Aside from the court’s interference with a religious precept that the ritual must take place long before adulthood, the judgment could ironically cause greater harm to one’s bodily integrity because circumcision for adolescents and adults, as compared to infants, is more complicated and has a higher rate of adverse effects.

First, civil law already interferes with many religious precepts because they involve harm to others. Interference is not necessarily improper.

To her point, the issue is consent to the harm inflicted. The right to bodily integrity involves the ability to consent to harm. Or not. If a male wishes to get himself circumcised, he can decide for himself that whatever benefits he values from non-therapeutic circumcision outweigh the harm and risks of further harm. Or not. The perceived increase in difficulty in adults is not an ethical argument in favor of infant circumcision.

Within the religious context, we need to evaluate the number of teens and adults who would volunteer for ritual circumcision if left intact from birth. I assume that number would be very high. I do not believe it would be 100%, at which point the implications to individual rights should become obvious. More on this in a moment.

Outside the religious context, the number of teens and adults who would volunteer for cultural circumcision if left intact at birth would be very low, as it is now. I also assume the number of medically necessary circumcisions would increase, but only on a volume basis. The percentage would likely stay low, apart from the consequences of unnecessary fiddling with the non-retractable foreskins of children by doctors and parents.

While there appears to be the difference between infant and adult circumcision Ms. Saperia cites, there are other differences. Consent is the largest, but there is also the ability to say how much skin the individual wants removed, if he consents. Does he want to keep his frenulum? As an adult, he can have greater amounts of pain management medicine, as needed. The case isn’t as convenient to their argument as proponents seem to believe.

Ms. Saperia’s conclusion calls for a recognition of community rights, within limits, to support multicultural acceptance and integration. This is lacking on medical grounds because it is objective harm for non-therapeutic reasons. It is lacking on legal grounds because analogous surgical interventions are treated unequally in law. It is lacking on moral grounds because it lacks the consent of the recipient. Every proof she attempted failed to demonstrate that non-therapeutic circumcision on non-consenting children should be permitted.

Coercion Negates Self-Determination

The German court ruling involves many issues, so I expect it to be an ongoing source for posts for the foreseeable future. I’m building my thoughts on the opposition, which is a complex issue. For this post, though, there are a few comments worth mentioning. The full article contains many quotes based on faulty logic, but this comment¹ encapsulates the problem with balancing parental religious freedom with a child’s right to be free from harm:

The Evangelical Church’s Hans Ulrich Anke said: “Religious freedom and parents’ right to choose how to educate their children have not been weighed against the fundamental right of the child to bodily integrity”.

Parents don’t have the right to educate their children with the blade of a scalpel. This is as true about male circumcision as it is for any other surgery, including religiously-argued female genital cutting. The right to be free from obvious, objective harm without one’s consent is not a right that begins upon reaching a society’s arbitrary age of majority. It’s especially fallacious to imagine that this right doesn’t exist from birth for male minors only, as laws against non-therapeutic female genital cutting imply. The fact that male circumcision is proscribed in religious texts demonstrates nothing about the legitimacy of its imposition on a healthy, non-consenting child in a civil society. There are many religious dictates that we do not allow under this expansive view of religious freedom because the actions violate the rights of others. A balancing test is necessary. Where there is a conflict, religion must change, not our protection of the rights of all citizens, equally.

This post by Iain Brassington at the Journal of Medical Ethics blog deftly addresses this conflict for what it is. (Mr. Brassington cites this news story.)

The president of Germany’s Central Council of Jews, Dieter Graumann, called it “an unprecedented and dramatic intervention in the right of religious communities to self-determination”.

That’s telling. The rights of the child give way to the right of a community to cut him. Can communities have rights anyway? I’m not at all sure. If they can, and if self-determination is one of them, does that always have to come out trumps? Again, I’m not at all sure. It’s strange to see rights-talk brought to the table in defence of unconsented, irreversible, and non-therapeutic body modification. If a boy decides that it’s important to get himself circumcised later in life, then that’s a different matter entirely: good for him. But without any choice? I may have missed something, but I don’t understand how the claim is supposed to work. Can anyone help out?

Mr. Brassington succinctly identifies the conflict. The argument is for community “rights” at the expense of individual rights. Effectively, children are property. I suspect critics of protecting a male child’s right to bodily integrity expect opponents to retreat on the basis of some form of fallacy to render reconsideration of existing norms unjustified and offensive. Unfortunately, but with reason for optimism, this is part of the path to achieving full protection of bodily integrity for all individuals.

¹ It’s possible to read that in a different context from the rest of the article. That subtlety may be what he meant, which would rather likely side closer to my view than with the other comments in the article. I will consider it in the context of the rest of the article, as criticism of the court and an attempt to support non-therapeutic child circumcision as a parental religious right.

Flawed Circumcision Defense: Yair Rosenberg

In what appears to be an attempt at a GOTCHA! in response to the German court ruling, Yair Rosenberg offers a weak effort touting the potential benefits of non-therapeutic circumcision. He opens:

“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.”

Who would you guess recently offered this paean to foreskin fleecing? A rabbi? An imam? Nope. Try U.S. AIDS coordinator Eric Goosby at a health convention last month for top officials from 80 countries.

This smacks down the logic of a German regional court that has banned religious circumcision, calling the practice a “serious and irreversible interference in the integrity of the human body.” …

Mr. Goosby’s statement, used as an appeal to authority, does not smack down the logic of the German court. Circumcision can impart potential benefits when it is imposed on a healthy child, while meeting the court’s statement that it is a “serious and irreversible interference in the integrity of the human body”. The imposition on a healthy child makes it unethical. There is no need for an allegedly-required belief that the science isn’t real. Mr. Rosenberg’s argument focuses on ends without a complete consideration of the means.

He next offers the inevitable appeal to a reduced risk of HIV. As almost every advocate does, he omits the relevant caveats. The risk reduction is in female-to-male HIV transmission in high-risk populations. Neither describes the HIV epidemic in any Western nation, including Germany. Even if it did, the studies involved voluntary, adult circumcision, not infant circumcision. That’s the ethical question. Infants can’t consent. They also won’t be having sex any time soon. There is no immediate need to force non-therapeutic circumcision on them for this potential benefit.

His next tactic is revealing. He quotes a story on the HIV studies. The story quoted unnamed federal health officials who declared that the studies were halted early because the findings made it “unethical to continue without offering circumcision to all 8,000 men in the trials”. Okay, fine, they offered circumcision to the control group. Mr. Rosenberg states:

Unethical not to circumcise the men.

No. Researchers deemed it unethical to not offer circumcision to the control group. That’s a huge difference. The control group men retained the right to reject circumcision. One might say this distinction is “highly significant”. Mr. Rosenberg seems to have missed the entire ethical issue. The issue is the imposition of circumcision, not whether or not someone could (or should) conclude that circumcision for himself is awesome because of various possible benefits.

He returns to an appeal to authority:

… The American Academy of Pediatrics is soon expected to come out with a new policy pushing circumcision, reversing its prior stance.

I’m not a fan of the “no medical association recommends it” argument because it’s an appeal to authority and because it could change. But the same problem applies to using a medical association’s support. In the latter case, it’s an evaluation without regard for what the individual needs or wants. It’s untethered from rights and reason.

He continues (emphasis added):

Given this impressive scientific consensus as to the medical dividends of male circumcision, the German court’s judgment—which permits circumcision for “medical reasons”—is a confused and ignorant muddle. Some have rightly criticized it as an assault on millennia of Jewish tradition and practice (not to mention Islam), something one would have thought a German court would be sensitive enough to avoid. But the ruling itself, as the research above amply demonstrates, is logically incoherent and factually wrong for a simple reason: All circumcisions are medically beneficial. Whether or not the procedure stems from religious motivations, it will have measurable health benefits. So by the court’s own reasoning, all religious circumcisions ought to be permissible as long as the parents also want the medical dividends—which effectively means that circumcision has not been banned at all. Of course, it is very unlikely that this is what the court intended and much more likely that it was entirely unaware of the scientific consensus surrounding circumcision’s advantages.

First, it seems clear that the court meant “medical reasons” to mean “medically necessary”. In saying that the court’s reasoning renders non-therapeutic circumcision valid based on merely mouthing the words “medical benefits”, he is echoing the silly argument many push that pretends prophylactic circumcision is “medical” circumcision. It is not. Non-therapeutic child circumcision involves proxy consent, not consent, so the only valid medical reason is need. As Mr. Rosenberg acknowledges, this interpretation is not likely the court’s intent. Assuming that this means the court was unaware of the science is too convenient. It begs the question. “They ruled circumcision is harm, so obviously they didn’t consider the benefits. If they had, they’d know that all circumcisions are medically beneficial and rule accordingly.”

Within either analysis, his conclusion is still wrong. The italicized bit is Mr. Rosenberg’s personal evaluation. It is his subjective conclusion based on his preferences. (He indirectly admits this later.) It is not an objective fact. The only objective fact is that circumcision inflicts some guaranteed level of harm. There is also the possibility of unexpected harm reflected in further complications, which contradicts his “all circumcisions” insistence.

Not everyone will value the potential benefits the way he does. I don’t. The HIV benefit he cites, the one that barely applies to Western societies, is effectively moot if a male simply wears a condom when he has sex. The same ease of prevention applies to HPV, for which there is also a vaccine approved for females and males already exists. And so on. The remaining benefits are generally achievable through less invasive preventions and/or treatments. The most invasive surgical option on children as a prophylactic measure can’t be justified ethically.

Or to put it in extreme terms, is circumcision medically beneficial to the boys who will lose more than their foreskin? What about the boys who die? Is circumcision medically beneficial to them? All circumcisions are medically beneficial, right?

He also misstates the goal of activists:

But that scientific consensus reveals more than just the follies of this German court; it also exposes the deeply problematic aims of American advocacy groups which seek to outlaw circumcision for the entire United States. …

The goal is to prohibit non-therapeutic circumcision on non-consenting individuals. It is not to outlaw circumcision, full stop. That’s his meaning, but precision matters here, just as it does when discussing the reduced risk of female-to-male HIV transmission in high-risk populations.

After trotting out the tired “why do you hate the poor?” argument, he writes:

… It’s one thing to abstain from a potentially medically beneficial procedure due to personal convictions; it’s quite another to enforce those convictions coercively on others.

Children who have circumcision forced on them do not get to abstain due to personal convictions. They had someone else’s convictions enforced coercively on them. If Mr. Rosenberg understands the ethical issues involved, he hasn’t shown it yet.

Ultimately, those who seek to ban circumcision as the essential equivalent of child abuse—from this German court to activists who recently attempted to bar the practice in San Francisco—are doing so in the face of tremendous scientific evidence to the contrary. Their claims are at odds with countless studies, not to mention global health policy. The burden of proof, then, is upon these activists to defend their disregard for this science, not on the majority of Americans who choose to circumcise their children and take advantage of its documented benefits.

This isn’t how the burden of proof works, since proponents of non-therapeutic circumcision on non-consenting children are the people advocating intervention contrary to the normal, healthy body. It warrants an answer, regardless. I do not disregard this science. I accept it all. I just don’t foolishly pretend that the possibility of a benefit permits me to disregard ethics or the vast amount of science beyond claimed benefits from non-therapeutic circumcision. The normal, healthy foreskin is science. The ability of soap and water to cleanse the penis, foreskin included, is science. Condoms are science. The power of antibiotics to treat infections is science. If we are to take Mr. Rosenberg’s narrow reasoning as a valid replacement for ethics, any surgical intervention on a child becomes acceptable if some rationale about possible benefits can be found. There is no limiting principle that respects rights. It’s based on one’s preference for circumcision about one’s child, without regard for what the child needs or might (not) want.

He concludes¹ with this:

After all, individuals are free to discount scientific evidence on the basis of value considerations, even dubious ones, and base their life decisions upon that calculus. But such subjective notions should never form the basis for coercive state policy any more than, well, religion.

Individuals are free to discount scientific evidence on the basis of value considerations. I do. I accept the benefits, but I value other aspects of the issue more. Ethics, bodily integrity, and normal body parts all matter more to me than the possible benefits. Whether that’s dubious or not for me is not for anyone else to decide. Yet I don’t have any freedom on this. My parents had me circumcised. They made my decision on their subjective calculus. It was the basis of their coercive parental policy. If the issue is force, and it is, the only illegitimate force exercised here is circumcising healthy children. Prohibition is the defensible position.

If we want to discuss whether prohibition is the best approach to solving the violation of non-therapeutic circumcision on non-consenting individuals, that’s a discussion worth having. Cultural change is likely to be far more effective. Society, in general, and religions, specifically, have changed. There’s no reason to believe it can’t happen here. It should. It will. In the meantime, though, children are having their decision made with force. Agitating for change through multiple avenues, including the law, is reasonable.

¹ He actually concludes with “Your move, Foreskin Man.” That’s not an argument. I’ve written what I need to say on that topic.

Flawed Circumcision Defense: Dr. Ruth Westheimer

At the risk of being impolite to Dr. Ruth Westheimer on her birthday, here’s a reminder of how lacking her position on male child circumcision is. From an advice column from 1995:

Dear Dr. Ruth: There is a good deal of anti-circumcision opinion in circulation these days and I would like to get your opinion. One of the claims is that circumcision results in a reduction of sexual pleasure. The argument, which sounds logical, is that exposing the glans reduces its sensitivity and that therefore the uncircumcised penis affords more sexual pleasure than the circumcised one. Sounds plausible, but is it true?

I think that many of today’s young parents, Jewish and others, who like to do what is “politically correct” might well forgo circumcision of their sons if that condition would mean someday depriving them of a measure of sexual pleasure.

Can you suggest any kind of evidence which either supports or challenges this claim?

Dear Reader: While it is true that one of the long-term effects of circumcision is some loss of sensitivity in the glans, or head of the penis, what you must realize is that sex really takes place in the brain, and so long as the man is in a loving relationship, there will be many compensating sensations taking place in his brain to replace those he might have lost in his penis.

She answers the question correctly (with an answer contrary to the mistaken opinion many hold today, almost 17 years later). While I understand what she’s doing, using the bulk of her answer to disregard the implication of her initial statement is inexcusable. The question involved children, not how to comfort a circumcised adult sexual partner. This disregard is still all too familiar today. “It affects his sexual pleasure, but…” There is no valid defense of that “but” for non-therapeutic circumcision on a child.

On her website, she answered another circumcision question. It’s undated. I assume it’s (considerably) more recent than 1995. It doesn’t matter. (emphasis added)

[Reader:] My wife and I are expecting, and we are not finding out the sex. However, if we have a boy, she is adamant that we not circumcise him, and I am adamant that we do. I have researched article after article about the hard medical facts of circumcision and how it lowers the transmission rates of STD’s such as HIV. It also helps with penile carcinoma, UTI’s, and ulcerative STD’s.

My intelligent wife believes that we should offer our son a choice of whether he wants it or not, and is afraid our son will feel the pain if he has it.

I am circumcised, and want my son to ‘look’ like daddy, as well as not have to explain to him at a younger age as to why he is so much different than daddy.

I’m interrupting here to highlight what is obvious. The father talks about all of the benefits he has researched. Yet, his statement makes it clear that his real reasons are that he wants his son to look like him and to avoid the need to parent his child with an explanation for why his son is “different” (i.e. normal). This is even though a son won’t ‘look’ like daddy for at least a decade after circumcision, which he will still have to explain if it comes up. Better to act like a parent and explain his normal, healthy body to him than to pretend that his dad’s insecurities justify surgery. (These insecurities will appear again.)

Furthermore, if the procedure is done later, our son will be in pain for six weeks, and I just don’t want him to have to endure that torture. [ed. note: so it’s acceptable to force him to endure that as an infant?]

As circumcision requires both parents consent, this matter will not resolve itself. I feel that my wife should consent as I have more experience in this matter than she does. [ed. note: This is stupid. Would he abdicate his responsibility as a parent if his wife wanted their daughter cut?] I would also feel inferior when our son asks, ” Daddy, why did you cave in to mom’s demands?” later in life. [ed. note: Protecting your children from harm is the “manliest” thing a father can do. Don’t pretend this is about proving your power and ego.]

We are at an impass. We are both passionate about our beliefs (she would consent to having our son circumcised if I were Jewish). What can I do? Should I let this battle go?

Before getting to Dr. Ruth’s answer, I didn’t interject into this man’s question to mock him. I only seek to indicate how obvious the rebuttals are that a good advice columnist would offer about this parenting question. His approach is quite common, so it shouldn’t be unfamiliar to Dr. Ruth. She didn’t go that route, of course.

[Dr. Ruth:] While it’s OK to have differences of opinions, I would hope that you don’t have to have actual battles over these issues. Perhaps because you’re both acting so stubborn, neither one of you is willing to listen to reason. And at this point, you don’t even know if it’s going to be a boy or a girl!

While you raise good points regarding the health concerns, those risks are greatly reduced if it is a boy and you teach him to clean his penis thoroughly. [ed. note: Indeed.] I know not every young male does a good job at that, but if this is important to you, then you’d just have to make it your duty to make sure he does. [ed. note: Parenting… What a useful answer.]

Your wife’s point that the decision should be his does not sound very intelligent. It is much worse to have this procedure when you are older, so the decision must be yours when he is quite young. If that’s her only concern, then perhaps your argument that you want his penis to look like his dad’s has more weight. But in the end, this is not such an important issue and rather than fight over it, you should have some reasonable discussions, if the baby turns out to be a boy, and see what happens. But better to lose this particular debate than fight with your wife.

Dr. Ruth’s last paragraph is a complete mess devoid of ethics. The wife’s point is the only intelligent opinion uttered throughout. As Dr. Ruth answered in another question (about an adult), “[i]t’s his penis …”. Yes. In that other question, if the argument that it’s his penis weren’t the correct answer, Dr. Ruth should’ve told the woman asking that question to demand that her boyfriend get circumcised. She didn’t. Self-ownership exists from birth. It is not negated simply because a boy’s parents fear a possible future outcome.

That gets to Dr. Ruth’s next failing here. She omits the critical point. What is the risk he will need to be circumcised later? It’s quite low, of course. In addition to the more important fact that there is no decision to be made now, there will likely never be a decision that needs to be made. Whether or not he might deem the prospects of adult circumcision to be worse is irrelevant. It does not mean the decision must be his parents’. Dr. Ruth’s opinion is not intelligent. Justifying cosmetic surgery on a son to appease his father’s ego is not intelligent, either.

(Her last sentence is an accidental correct answer. She found her way to a good suggestion premised on an awful reason.)

More on the Fallacy of VMMC: Infant Volunteers

Following on last week’s post detailing how voluntary is deceptively dropped from “voluntary male medical circumcision” (VMMC) when convenient, it’s worth demonstrating how the U.S. government engages in the same unethical behavior. Both USAID and PEPFAR are guilty.

Starting with USAID, its Technical Brief (pdf) on Medical Male Circumcision and HIV Prevention drops voluntary from the title of the document. Then, despite including the “V” in the document, it writes (italicized emphasis added):

Providing VMMC Services

As targeted activities progress, demand for VMMC services by interested adolescent and adult males and the parents of male early infants has increased. …

Costing and Impact Summary

To further support VMMC program planning, PEPFAR worked through USAID to collaborate with Joint United Nations Programme on HIV/AIDS (UNAIDS) to develop the Male Circumcision: Decision Makers’ Program Planning Tool to assist countries in developing policies for scaling up services to provide VMMC. This tool allows analysts and decision makers to understand the costs and impacts of different policy options regarding the introduction or expansion of VMMC services. It is part of a larger toolkit developed by UNAIDS/WHO that provides guidelines on comprehensive approaches to VMMC, including types of surgical procedures and key policy and cultural issues.

The key policy topics addressed by the model are:

  • Identifying all male adults, adolescents, and early infants; targeting coverage levels and rates of scale-up
  • …

Key conclusions from an initial desk review study presented at the International AIDS Conference in Vienna,Austria, in July 2010 indicate that scaling up VMMC programs to reach 80 percent coverage of adult and early infant males within 5 years could potentially:

  • …

The entire report is preposterous for how uninterested USAID is in dealing with the obvious ethical problem. Society has simply accepted that, as long as someone “volunteers” a person, that person has volunteered for circumcision. There’s no apparent sense that ethics matter, or that language indicts interest and intentions.

Notice, too, PEPFAR’s cooperation with USAID to ignore voluntary. It continues within PEPFAR documents. First, from “Smart Investments: Making the Most of Every Dollar Invested” from February 2011 (italicized emphasis added):

Medical Male Circumcision

Medical male circumcision (MC) is an ideal HIV prevention investment for countries and donors as it is a time limited intervention. The majority of the expenditure required to saturate a country with high levels of adult male circumcision takes place in the first 1-3 years, depending on the speed of the program, and expenditures drop precipitously following this initial investment to support neonatal and adolescent boys. Scaling up of MC to reach 80% of adult and newborn males in 14 African countries by 2015:

  • …

As expected, voluntary makes no appearance. Instead, the passage just assumes that adult and infant circumcision are the same. No differences, no questions raised in the latter. It’s pure utilitarian decision-making without concern for the patient. The individual is merely a part to be directed.

Next, more blatantly, PEPFAR’s “Guidance for the Prevention of Sexually Transmitted HIV Infections” (pdf) contains the following (italicized emphasis added):

4.2.2 Voluntary medical male circumcision (VMMC)

Evidence

Voluntary medical male circumcision is the surgical removal of the foreskin from the penis [ed.note: of a consenting adult] by trained medical personnel under aseptic conditions. …
…

Program Implementation

Countries with a low prevalence of male circumcision and high HIV prevalence should initiate and accelerate steps to increase the availability of VMMC services. As with other prevention methods, considerations of access and cost, as well as cultural, ethical, and religious factors can hinder the widespread implementation of VMMC. …

Implementation of the comprehensive HIV package: Where VMMC services are provided, … PEPFAR will support programs, in keeping with national strategies, that: implement the comprehensive package; adopt culturally-appropriate strategies; utilize well-trained practitioners working in sanitary conditions; maintain informed consent and confidentiality; and avoid any form of coercion.

Targeted implementation: UNAIDS and WHO advise that the greatest public health benefit results from prioritizing circumcision for young males (such as those aged 12-30 years), as well as men thought to be at higher risk for HIV (such as those in discordant couples or being treated for STIs). Circumcision of newborn babies should be promoted as a longer-term strategy. VMMC for men living with HIV is not recommended but should not be denied if requested.

Short-term, accelerated implementation: … Once intensive service provision accomplishes “catch-up” circumcision for adolescent and adult males, sustainable services need to reach only successive cohorts of young adolescents and/or newborns. These”catch up” programs require awareness and behavior change communication campaigns wherein political and social leaders promote VMMC. …

PEPFAR didn’t bother to drop the “V” from voluntary medical male circumcision. It just pretends that any circumcision of a male is voluntary. According to PEPFAR (i.e. the U.S. government), a 12-year-old male is the same as an adult and can volunteer with full, informed consent. I believe that’s possible, but not in any way applicable to all 12-year-old males. (This is especially true given how rarely advocates provide any mention of the functions and benefits of the foreskin.) It’s in no way applicable to any infants, yet that is the long-term strategy PEPFAR is pushing. Voluntary has disappeared as a consideration.

Even accepting the flawed view of the success possible from pushing circumcision of infants for HIV prevention, what happens if it proves successful? Those locations become populations with high prevalence of circumcision and low prevalence of HIV. They become the exact opposite of what they say in the above and in this from the Evidence section:

WHO and UNAIDS have concluded that VMMC should be actively promoted as part of comprehensive HIV prevention efforts in settings where circumcision rates are low and HIV prevalence is high. …

Its own success would render it no longer ethical (within the unethical frame of “voluntary” infant circumcision). Would advocates stop pushing circumcision – infant circumcision, specifically – as an HIV risk reduction method? Given the behavior of U.S. advocates, including the AAP, I’m skeptical.

I’m not doubting their sincerity. I believe people can be sincere in their ideas as a result of flawed, poorly examined assumptions. I doubt their sincerity in accepting the correct assumption that voluntary medical non-therapeutic male circumcision may be advisable only in areas with low circumcision rates and high HIV infection rates. Infants do not volunteer, and there’s a long grace period during which better (or complete) prevention methods may be discovered. Or advocates might remember that condoms are necessary, regardless of circumcision status. But they don’t. Somewhere the goal not-so-subtly morphed from “circumcision for HIV prevention” to “circumcision and HIV prevention”. As the last century-plus demonstrates, advocates of circumcision tend to believe that circumcision justifies itself. What an individual might want in the absence of need (i.e. ethical, voluntary circumcision) fades to public policy insignificance, or worse, becomes assumed away to a position where infants beg to be circumcised now. Reports on VMMC that are really just a push for MC provide modern, ongoing proof.

**********

This additional bit from PEPFAR’s guidance is informative, as well:

Current evidence strongly supports VMMC‘s effectiveness in preventing infection of men in penile-vaginal intercourse, but not in penile-anal intercourse. While statistics have been inconclusive thus far on the efficacy of circumcising MSM to prevent infection, the procedure may be worthwhile for individual MSM, especially those who also engage in sex with women. …

Statistics have been inconclusive, but it may be worthwhile. That’s “heads I win, tails you lose” analysis in pursuit of circumcision for the sake of circumcision.

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.