Category: “Voluntary”

Sexual Control: Making a Permanent, Unnecessary Decision for a Child

It’s rare to find a blatant attempt to explore justifications for the use of male circumcision as a form of sexual control. From Thursday’s debate on SB12-090 (pdf) within the Colorado House Health and Environment Committee, State Representative Sue Schafer directed a request to Dr. Jennifer Johnson. Dr. Johnson testified against the bill, specifically, and child circumcision, generally. Within Dr. Johnson’s opposition, she discussed the nerve endings in the foreskin lost to circumcision. Rep. Schafer asked (audio, excerpted from the legislature’s archive):

Rep. [Lois] Court said earlier “there are no dumb questions”, and that we will speak in a respectful manner, but I’m concerned about the rate of teen pregnancy, the rate of date rape, sexual violence, and when you talk about more nerve endings in the penis, in the foreskin, I’m just wondering if there’s any risk of more sexual activity among young men, more male irresponsibility, so if you’d be good enough to comment on that.

That question isn’t dumb. It’s offensive and insulting. Her underlying implication is that, if non-therapeutic male circumcision could be shown to lower the occurrences of what she’s concerned about, that would dismiss the ethical concerns about negatively affecting male sexuality that apply to every male child circumcision. It implies that it’s acceptable to control male sexuality (i.e. permanently reduce it) to limit sexual activity during teen years. It implies that males may inherently be incapable of controlling their own sexual behavior. There’s also the possibility that her implications are targeted only at the poor, the subject of this bill to restore Medicaid funding for non-therapeutic circumcision. I suspect her concern is for the general application of circumcision upon males, not just poor males covered by Medicaid. Regardless, Rep. Schafer’s question exposes the issue and its connection to unquestioned parental proxy consent for male circumcision, a permanent, non-therapeutic surgical intervention.

It’s useful to have this clear example because it’s a common misconception that male circumcision of minors involves no control or attempted control over male sexuality. That’s a misconception because non-therapeutic male child circumcision is always control. The patient receives only someone else’s idea of what a “normal” penis should be. He can no longer exercise control over his normal, healthy body, only his altered body. The flaw is most commonly some form of drivel about the preferences of the boy’s future sexual partners, which is speculation, but it applies to religious justifications, as well. Someone else imposes what the child “should” want. The truth is clear: all non-therapeutic child genital cutting controls sexuality.

The challenge to defeating the common misconception rests on separating parental intent from the act. The accepted argument entails the idea that male genital cutting can’t be something bad because the parents have good intentions. American parents think they’re doing what’s in the best interests of their sons, so we’re told we must accept that this negates the obvious reality of what the act is and does. That’s flawed because the act matters before we consider intent. Parents do not intend harm, but circumcision (i.e. surgery) causes harm. We can – and must – make a judgment on the act without regard to intent because it’s a non-therapeutic intervention on a non-consenting individual. It fails ethics.

Fact Sheet

The WHO fact sheet on FGM is excellent, for what it does. I’ve modified and condensed it below into a universal, concise fact sheet on genital mutilation that respects equal human rights for all (male, female, and intersex) individuals.

Genital Mutilation

Key facts

  • Genital mutilation (GM) includes procedures that intentionally alter or cause injury to the genital organs of a non-consenting individual for non-medical (i.e. non-therapeutic) reasons.
  • GM is a violation of human rights.

Genital mutilation (GM) comprises all procedures that involve partial or total removal of the external genitalia of a non-consenting individual, or other injury to the genital organs of a non-consenting individual for non-medical (i.e. non-therapeutic) reasons.

GM is recognized internationally as a violation of human rights. It reflects deep-rooted inequality, and constitutes an extreme form of discrimination against children. It is nearly always carried out on minors and is a violation of the rights of children. The practice also violates a person’s rights to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death.

Procedures

Genital mutilation is classified as:

  • Any surgical interventions or harmful procedures to the healthy genitalia of a non-consenting individual for non-medical (i.e. non-therapeutic) purposes

No therapeutic benefits, only harm

GM has no objective, immediate therapeutic health benefits, and it harms individuals in many ways. It involves removing and damaging healthy and normal genital tissue, and interferes with the natural functions of the individual’s body.

The Duty to Run Interference

Author John Scalzi posted an essay on his blog, Whatever, from an unnamed friend who is a doctor. It discusses the recent furor over the political push for transvaginal ultrasounds mandated for political “need” rather than medical usefulness. The essay is well-worth reading. I wish to post an excerpt relevant to my purpose for Choose Intact because it involves a doctor’s responsibilities in medical intervention. The doctor is concise, specific, and irrefutable. The logic is as applicable here as it is in non-therapeutic transvaginal ultrasounds.

It is our responsibility, as always, to protect our patients from things that would harm them. Therefore, as physicians, it is our duty to refuse to perform a medical procedure that is not medically indicated. Any medical procedure. Whatever the pseudo-justification.

It’s time for a little old-fashioned civil disobedience.

And from the doctor’s proposed step two to protect patients from such legislation:

Our position is to recommend medically-indicated tests and treatments that have a favorable benefit-to-harm ratio… and it is up to the patient to decide what she will and will not allow. Period. Politicians do not have any role in this process. NO ONE has a role in this process but the patient and her physician. If anyone tries to get in the way of that, it is our duty to run interference.

An excellent summation of the physician’s responsibility to his/her patient.

“Since not all men are willing to be circumcised,…” (Part 2)

Update (5/31/2012): To the extent appropriate, my update to Part 1 applies here. I have not edited anything in this post, though. [End Update]

Note: Here is Part 1 of this series rebutting the recent meta-analysis purporting to demonstrate that infancy is the best time to impose circumcision on healthy males.

The interesting thing about the Brian Morris, Jake Waskett, et al article, “A ‘Snip’ in time: what is the best age to circumcise?”, is how reckless they are with their logic. They toss out information without regard for obvious rebuttals or how unrelated the so-called evidence is to their conclusion. If they think it might stick, they include it. One can only conclude that they started with the outcome of their analysis before gathering the supporting data.

For example, in their conclusion, they write that early circumcision “means an assurance of greatly reduced risk of penile cancer later in life, no smegma, better hygiene, and lower risk of various STIs.” They don’t include anything on why smegma is supposedly bad and thus indicates circumcision is not only good, but should be imposed on healthy infants. I’m sure they can find something, although I doubt it would be compelling. There’s also the logical question of why it’s an indication for non-therapeutic genital cutting on boys but not girls, who also develop smegma.

They continue this effort in their conclusion. In a sub-heading they write:

Some of the arguments against waiting until later to circumcise are:

• The cost (to the individual or the public purse) is much higher, and often unaffordable, for later circumcision.

The cost to the individual who doesn’t need circumcision later in life is zero. That population would be very large for males left intact. Even from the irrelevant “public purse” approach, they would need to calculate the cost of therapeutic circumcision paid for by they public later in life against the cost of non-therapeutic neonatal circumcision (cost per instance X number of instances). They don’t.

Also, the time value of money must be factored into the comparison. A dollar spent today is not the same as a dollar spent twenty, thirty, or more years from today. The number of adult circumcisions needed would have to be even greater to justify their public purse argument. It still wouldn’t be ethical to circumcise healthy infants, of course.

That’s not the worst “argument against waiting” they offer. This is:

• Educational resources for boys to make an informed decision are quite limited.

I had to read this several times to be certain it said what I read. They can’t be this ridiculous. They are.

The immediate, obvious rejection of that nonsense is that boys (and adult males) can use the same educational resources Morris, Waskett, et al suggest parents use to make an “informed” decision. Surely they exist, or else the position that parents can make an informed decision without adequate educational resources is irresponsible. What makes the male himself too stupid to understand the same materials? There’s no defense for their statement or their conclusions.

They offer a few more:

• Boys who later choose circumcision will likely wish it had been circumcised in infancy.

This is the bizarre argument I’ve encountered from Waskett, the mythical “right” to grow up circumcised. But this is the radical position. Boys who would later reject circumcision can’t undo the harm imposed on them. The authors incorrectly dismiss this. It is the center of both the physical and ethical argument against non-therapeutic child circumcision.

• Many older boys and men may not want to face an operation even though they wish to be circumcised.

That ties to a statement earlier in their article:

Even if a man is willing to be circumcised this does not mean he will end up having the procedure done. On the other hand, a lack of willingness to be circumcised should not be interpreted as a preference to be uncircumcised. This is because a large number of obstacles have been documented, such as fear of pain or complications, embarrassment, inconvenience and cost. The obstacles are discussed in the following sections. It is reasonable to suppose that, if these barriers could be addressed through the provision of correct information and financial assistance, the fraction of men willing to be circumcised would increase significantly. Better education of parents before or soon after their baby is born about actual risks should, by helping to ensure a circumcision in infancy, avoid later deliberations and barriers to circumcision in adolescence and adulthood.

That’s very convenient for their preference. Just assume anything that helps your position and disregard anything the suggests something else. Notice the shift in that paragraph. The last sentence of that paragraph has zero relation to the rest of the paragraph. A male’s refusal to be circumcised despite a claimed desire to be circumcised demonstrates that he values avoiding the costs more than receiving the benefits. The only reasonable supposition is that the infant would likewise be unwilling to undergo circumcision if left his choice. The authors’ suggestion is nonsense.

There is at least one more installment to come.

What Applying the Science Says About Circumcision

It’s frustrating to read people writing about the science of non-therapeutic infant circumcision while omitting ethics and a full consideration of what constitutes harm. Such is the case with a series of posts at SquintMom. The blogger, Kirstin, is doing a series of three posts, “What the Science Says About Circumcision”. Part 1 on the benefits is here. Part 2 on the risks is here.

I have a lot to say on the two entries posted so far, but I’d rather organize my thoughts into identifying a more generalized flaw in the series. As I said, this is primarily the ethics of applying the science. Several times in Part 1, she uses parentheticals to explain the circumcised men in the studies. “With their permission”. “With their consent”. This matters. She concludes that there aren’t enough benefits to support routine circumcision in the U.S., which is the right conclusion. But her assumption seems to be that some level of benefit could justify routine infant circumcision. That’s too utilitarian. Individuals have different levels of risk aversion. A male’s willingness to accept risk may be greater than his parents’. We can’t know. Even if our HIV problem in the U.S. matched that of sub-Saharan Africa, I wouldn’t want to be circumcised. I’m responsible. I do not need circumcision to reduce my risk beyond the trivial risk I would face. No level of benefit could justify circumcising me without my permission and consent.

A willingness to carry “I don’t know” through its implications is the better conclusion for Part 2. That’s not what she offers. It’s incorrect to say “[i]t’s fine to make a decision based upon values”, as she did in her intro to Part 1. Circumcision causes physical harm, contrary to her conclusion. That she thinks that isn’t “significant”, a subjective word in the application of the science to healthy individuals, isn’t relevant to what we should allow parents to do to their – male, only¹ – children. What does the healthy male want? She mistakenly gives this no weight in her conclusion.

On the topic of harm, it’s worth starting on the legal point. Legally, all surgery is battery. Circumcision is surgery. Therefore, circumcision is battery. It is physical harm. It removes the normal, healthy foreskin. It involves risks, however insignificant they may seem to anyone other than the patient. Someone will be the statistic. He matters, too. (Again, this omission is why utilitarianism is awful.) It leaves a scar in every case. There is objective, guaranteed physical harm. To conclude that there is no physical harm to every circumcised male rather than just those who experience complications, as she did, is factually incorrect.

The legal defense to surgery as battery is consent. But non-therapeutic infant circumcision involves proxy consent, which requires a different standard. The objective is least invasive procedure possible that preserves the patient’s choices to the greatest extent possible. Since there is no procedure indicated because the child is healthy, there is no decision to be made. Permitting non-therapeutic circumcision is unethical. To address SquintMom’s recent post, “Options, Ethics, and Moral Imperatives”, a society’s overarching social philosophy can be wrong. Here, it is because non-therapeutic (i.e. “routine”) child circumcision involves objective, permanent physical harm without objective benefit.

As an example of where SquintMom went astray, I think this is a solid example (emphasis in original):

While the foreskin has sensory function (Taylor et al), there is no scientific evidence to suggest that the loss of these receptors affects sexual satisfaction or the intensity of the sexual experience for men. One study even goes so far as to suggest that while there isn’t currently evidence to support the notion that circumcision somewhat desensitizes men, even if such evidence existed, it wouldn’t necessarily be a bad thing, given that more men (and their partners) complain of premature ejaculation than complain of inability to achieve orgasm (Burger et al). While Burger doesn’t go so far as to suggest circumcision to prevent problems with premature ejaculation, these observations do put into perspective the “intactivist” argument that circumcised men don’t enjoy sex as much as they otherwise would; clearly, for the vast majority of men, enjoying sex isn’t a problem. The scientific evidence does not support the notion that male circumcision diminishes sexual performance in men, nor sexual satisfaction in men or women.

First, note the utilitarianism again. The foreskin has sensory function, but no evidence suggests… More men complain of X than complain of Y. That doesn’t eliminate the possibility that a man will want that sensory function or the concern for Y and the individuals who experience that. (I do not assume it is a direct result of circumcision.) Apart from the obvious fact that the loss of that possibly irrelevant sensory function still constitutes harm, SquintMom’s statement implies that all men value everything in the same way, or that they “should” value X more than Y. That’s obviously false. I don’t like coffee. Therefore, you don’t like coffee. Valid?

Clearly, for the vast majority of men, enjoying sex isn’t a problem. Yep. So? The better response is to carry through the implications of “I don’t know”, since we can definitively say not all circumcised males will enjoy sex. Specifically, we need not go beyond the men who are the statistics, the ones who incur a complication that is severe. The number of males who lose their glans, their penis, or their life is small, but the number is not zero. Who is going to be that male? We don’t know. Permitting parents to cause harm by applying the science of “no scientific evidence of harm” to their healthy – male, only – children means there will be males who either don’t enjoy sex or don’t live to enjoy sex. Applying the science of “no scientific evidence of harm” also assumes we won’t find any evidence in the future. The truth is that we don’t know.

She mostly expresses this point (e.g. “untestable claim”), but it’s not complete. Even ignoring what I wrote above on harm, it’s not definitive from her case that there is no physical harm from male circumcision. There is the possibility we’ll know more. In proxy consent, it doesn’t make sense to then apply the science of today permanently to the healthy body of another person based on parental values.

**********

¹ In her first post, she prefaced the series with “[f]emale circumcision is a completely separate practice, occurring for the express purpose of destroying sexual function.” She is wrong on both positions. (She repeats the former in the comment section of Part 2.) Female genital mutilation is usually imposed with that purpose, but not always. Cultural behaviors are complex, as she points out in her series. Why should it be different on something we (rightfully) abhor? (c.f. Consider these three posts.)

Anyway, the comparison is non-therapeutic genital cutting on a non-consenting individual. It can’t be wrong for one gender but acceptable for the other. There is no parental right to cut sons. That’s a bizarre world in which males and females have unequal rights to their own bodies. There is either a parental right to cut the genitals of healthy children, or no such right to cut healthy children. We rightly call the removal of a healthy girl’s clitoral hood “mutilation”. There is no ethical, legal, or scientific distinction to avoid protecting the analogous healthy body part in males.

This is what the World Health Organization states on FGM. It consists of four types, including type 4:

Other: all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.

Surgical alteration of the normal human body is harm.

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.

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 of cultural values? That’s absurd.

“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.

Quoting Dr. Doug Diekema Against the AAP’s Position

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

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

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

For example:

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

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

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

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

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

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

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

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

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

“Like Mother, Like Son”

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

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

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

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

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

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

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

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

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

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

Donations Are Voluntary, Not Taken

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

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

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

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

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

The ethics of the “donation” are grotesque:

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

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

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

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

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

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On a closing note, from the second article:

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

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