“…but most of them pick themselves up and hurry off as if nothing ever happened.”

Rebecca Steinfeld describes Elissa Strauss’ essay, How Female Circumcision Is Different From a Brit Milah, as “badly researched & poorly argued”. Ms. Steinfeld is correct.

Fighting against female circumcision, also known as female genital mutilation, is a no-brainer of an issue. Who could support the use of often unsterilized blades to slice off, in the least-invasive case, a portion of the clitoris, and, in the worst case, the whole clitoris and the labia, which are then sewn together, leaving just a small hole for the release of urine and menstrual fluid?

Obviously, but the inclusion of “often unsterilized blades” is irrelevant in the ethical analysis of FGM compared to male circumcision. Using unsterilized, non-surgical equipment is egregious, but that is a violation of medical standards within the context of a rights violation. The violation is wrong, even if it is performed using top-notch equipment with trained staff in a sterile environment. Of course, the appropriate strict standard implied is neither required nor adhered to for religious male circumcision, so the distinction hardly matters.

The degree of harm is relevant to the act. It should inform punishment. It is not relevant to the core ethical principle.

But before we Jews start fastening our anti-FGM pins to our messenger bags and sharing petition links on social media, we have to contend with the elephant in the room. You know, the one with the mohel on top.

Indeed, many fighting female genital mutilation see male circumcision in the same light, viewing both procedures as a violation of basic human rights because both are done without consent or reasonable medical justification. …

Yes. This is the place Strauss should’ve stopped. She proved the comparison. Instead, an appeal to authority:

The World Health Organization sees a big difference between the two procedures, describing female circumcision as having no health benefits and as “a violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women. It is nearly always carried out on minors and is a violation of the rights of children.”

FGM may reflect deep-rooted inequality. That’s debatable, given that the common idea that it is imposed by men on women is more complicated than normally stated. The last sentence, though, applies to male circumcision. That’s the comparison. Both are non-therapeutic genital cutting. Imposing that on a non-consenting individual (e.g. a minor) violates that individual’s rights. There is no asterisk on the right to bodily integrity for whichever distinction a person needs to impose it.

The WHO casts male circumcision in a very different light, describing it as “one of the oldest and most common surgical procedures worldwide, and is undertaken for many reasons: religious, cultural, social and medical. There is conclusive evidence from observational data and three randomized controlled trials that circumcised men have a significantly lower risk of becoming infected with the human immunodeficiency virus (HIV).”

I’ll grant these unequivocally, despite potential objections. So? They do not negate the ethical objection. There are any number of non-invasive preventions and treatments available to achieve these benefits. Some of them, such as condoms, are still necessary after circumcision. The ethical issue exists in part because not everyone shares the same preferences. Some would choose their foreskin and its alleged risks over circumcision and its alleged benefits¹.

Both female and male circumcision are motivated by custom: the surreptitiously stubborn notion of “This is what we do.” But the cultural setting accommodating the customs, as well as the physical ramifications of the procedures, reveal stark differences, and to ignore them is to demean the experience of the 135 million women and girls around the world who have had their genitals mutilated.

Those stark differences are often real. But Strauss already demonstrated the valid ethical comparison, before the added question begging. Mentioning that more extreme aspects of some FGM practices exist maybe shows that one is more wrong, but it doesn’t change that both are wrong.

Opposing non-therapeutic male child circumcision does not demean the experience of any female victim. This argument is a common fallacy. It’s clear that their experience is traumatic. The violation is obvious, real, and unethical. The results are usually more extreme than the results of male circumcision. The comparison is one of ethics, not harm. It is not a competition of victimhood. As I’ve often said, a punch to the face is not the same as a knife in the stomach. Because the latter is worse, the former isn’t a violation? That’s silly.

A common trope appears in the comments that feeds directly from Strauss’ approach. Twitter user CpaHoffman posted this comment (emphasis added):

Jews circumcise their male babies because we are commanded to by the Torah; it doesn’t hurt them (if it did, we’d have died out long ago). Female genital mutilation is not a “moral equivalent” or even on the same planet. Yet the lunatic fringe needs to drag it into every discussion of circumcision and needs to compare the two as if they were different yogurt brands.

It’s not comparing “apples and oranges”; it’s comparing apples and poison oranges.

That is a convenient straw man, but the argument against violating a child’s rights isn’t that it kills. (Although it can and does.) Death is not the only form of harm from circumcision. All surgery involves harm, including circumcision, which should be apparent since a normal part of the body is removed². Imposing that harm without direct need or consent that can’t be resolved with less invasive methods is unethical. Just like non-therapeutic genital cutting on female minors.

¹ These benefits can be medical, religious, or cultural.

² This is a different analysis than whether or not a surgery is a net harm.

The Majority of This Post’s Authors Oppose Unethical Practices

It’s no longer surprising to see the hyperbole concocted to make circumcision appear legitimate. The latest example comes from the Southern Africa HIV and AIDS Regional Exchange, which summarized a survey with the following:

New study in Kenya reveals the majority of women prefer circumcised partners

To summarize the study – Women’s Beliefs about Male Circumcision, HIV Prevention, and Sexual Behaviors in Kisumu, Kenya, by Thomas H. Riess, Maryline M. Achieng, and Robert C. Bailey – the way SHARE does is presposterous. The study involved 30 women, with 23 of them saying they preferred circumcised men. The proper way to summarize it is the second line from the abstract:

Women’s beliefs about MC and sexual behaviour will likely influence the scale-up and uptake of medical MC.

Counter to SHARE’s summary, the authors note (emphasis added):

There are limitations to this study. Since we relied on self-reports it is possible that some respondents could have fabricated answers or not fully disclosed information based on what is socially acceptable, particularly on sensitive topics such as sex and HIV. We did attempt to select respondents who were representative of sexually active women ages 18-35 but given the small sample size and geographic location of our research, our data might not be generalizable to other populations, particularly those where MC is not being promoted as HIV prevention. Our intention has been to gain insights into female perceptions and sexual behaviors related to MC in western Kenya in order to inform and improve programs scaling up MMC for HIV prevention in the region.

It’s misleading to report the study as revealing what the majority of women prefer.

Of course, it’s irrelevant what the majority of women prefer. The ethics center on what the male prefers for himself. In what ways could we rewrite this paragraph to allegedly demonstrate something about what women should do – or have done to them – to conform to the preferences of men?

Respondent: Actually, me personally, I hate uncircumcised men.
Interviewer: Why?
R: I just feel they are dirty and, … this last time, some other guy seduced me, … I didn’t know he was uncircumcised. So when we went out a bit for around four months, so it’s this day was he was telling me like we go to bed, after finding out that the guy is uncircumcised I just told him it can’t work. He should go get circumcised first and come back.
I: So how did he react?
R: Well actually he felt bad, but later he came to understand. That is when he went and got circumcised and we are together now. (25 year-old Luo woman)

Body shaming is body shaming, whoever its target may be. Repeatedly the excerpts emphasize a belief that circumcised men are “clean” and intact men are “dirty”. While the authors note this, and are perhaps genuine, in saying:

… While some women support MC based on their personal experience and beliefs, there may also be the potential for discrimination against uncircumcised men as circumcision programs scale up in sub-Saharan Africa. …

I find no reason to believe public health officials cared or will care. Discrimination is a strategy of these campaigns, as in this awful propaganda ad from Uganda. And the tactic is already paying the expected dividends. The interview excerpts in this study are evidence of that:

I: Do you desire circumcised men?
R: Of course a circumcised one (laughs).
I: Why not the uncircumcised one?
R: I don’t want diseases. (22 year-old Luo woman)

And:

I: And say you get some man who is not circumcised, what will you do?
R: You tell him that circumcision is good, a circumcised person has less chances of getting infected with these diseases, these minor diseases.
I: And if he still refuses?
R: If he refuses you just leave him. (27 year-old Luo woman)

The excerpts also reveal the well-tested “heads, circumcision wins / tails, foreskin loses” approach to sexual satisfaction.

… no matter how the lubrication is, that foreskin will, I don’t know, it moves … and then let me say they don’t stay long. … Yeah they didn’t stay long when you guys are the uncircumcised. Out of curiosity I did ask how come you don’t take long. They say like if that skin is moving it makes them crazy and they release so fast, and I said, okay. And then unlike the circumcised people maybe it’s to our advantage, the ladies, maybe it could be not to them but I think to our advantage they’ll take long. Like they might make you reach a peak faster than the uncircumcised. (23 year-old Luo woman)

The authors state that circumcision campaigns “should ensure that MMC promotion campaigns and counselling are clear that studies have shown that MC does not affect male time to ejaculation.” But campaigns like this count on individuals to sell the message, however well they grasp or fail to grasp that message. Intentionally engaging people to market on behalf of public officials involves spreading anecdotal evidence. There is no comfort or absolution in “the studies show” once they’ve started the game of telephone.

There also remains the possibility that the sources for the claim that circumcision does not affect male time to ejaculation are inaccurate. Note, too, that whether or not the male considers this change good is nowhere to be found. The ethical issue remains absent in this push for networked propaganda.

Human Rights as Politics rather than Principle

What is it about the basic concept of human rights that confuses so many people, such as U.N. High Commissioner for Human Rights Navi Pillay:

FGM is a form of gender-based discrimination and violence. It is a violation of the right to physical and mental integrity. It violates the right to be free from torture and other cruel, inhuman and degrading treatment. Because it is almost always practised on young children, it is also a violation of the rights of the child. FGM violates the right to the highest attainable standard of health, including sexual and reproductive health. And when it results in the death of the person who is mutilated, it violates the right to life.

I’d state it as the rights of self-ownership and bodily integrity, but still, even this way it’s easy to understand. Cutting an individual’s healthy genitals without the person’s consent violates rights. So why staple on this (emphasis added):

This harmful and degrading practice is not based on any valid premise. FGM has no health benefits. On the contrary, it generates profoundly damaging, irreversible and life-long physical damage. It also increases the risk of neonatal death for babies born to women who have survived it.

The answer is obvious to anyone who spends any time studying the issue of genital cutting. It’s a method that attempts to distinguish female genital cutting from male genital cutting. It shows up over and over. It’s transparent and wrong because it’s politics at the expense of human beings. The principle isn’t gendered. Non-therapeutic genital cutting on a non-consenting individual violates the individual’s human rights, full-stop. That is the human rights principle involved. The potential health benefits a child’s parents may cite can’t be a valid premise for non-therapeutic surgery without the child’s consent.

That isn’t my primary point here, though. The “FGM has no health benefits” approach is short-sighted and obtuse in the push to end FGM. It contains an implicit argument that FGC – not FGM, because unnecessary genital cutting without consent somehow can’t be mutilation – would be acceptable if some health benefit could be reasonably claimed. It’s a way of saying that human rights are important, but only to the extent that someone can’t find an excuse people are willing to accept as justification for ignoring obvious violations. It demonstrates that the person making the argument does not understand the implications of defending human rights and the courage it requires to be consistent to the principle. This tactic is not a framework for considering humans and their rights. It’s a strategy uninterested in human rights principles. It’s a strategy of manipulating emotions to achieve an ideological goal.

I’m not familiar with the source material, but I think this Friedrich Nietzsche quote I stumbled on today works well in this context (via):

“The most perfidious way of harming a cause consists of defending it deliberately with faulty arguments.”

That’s what the “FGM has no health benefits, so it’s not acceptable like male circumcision” argument is when attached to a human rights argument. If you claim to defend human rights, you have to defend human rights, not the politics of favored human rights.

Some of us wouldn’t dream of having any procedure

There is an inherent flaw always present in “parents should decide on genital cutting (but only for boys)” essays. An asinine dismissal of the ethical principle will exist. Although the case against must be made each time, the ethics obviously do not support that stance. Non-therapeutic genital cutting on a non-consenting individual is unethical. It violates bodily autonomy. Any facts supposedly in favor of at least allowing parents to decide can’t overcome this basic principle. So when an essay is titled “Why the decision to circumcise should be left in the hands of the family”, the flaw is guaranteed to be there. It’s the only way to seemingly make the premise hold. Yet, I’ve never seen the flaw so ridiculously written as in Dr. Jeremy Friedman’s essay.

Deep into the essay (emphasis added):

I understand that there are many vocal groups who feel that circumcision has a negative effect on sexual function and pleasure. I also realize that some feel it is unethical to remove something from an infant’s body without a clear medical need and without the infant having some input into the decision.

As a pediatrician, I’m not really professionally qualified to discuss the merits of these viewpoints but I respect the right of those individuals to express them. I am, however, qualified to tell you that babies are capable of experiencing pain and I don’t think it is acceptable to perform a circumcision in a newborn without some form of analgesia. There are a number of different options to prevent pain, and this should be discussed with the practitioner chosen to do the procedure, well ahead of the circumcision.

Dr. Friedman stated that he’s not professionally qualified to discuss the merits of these viewpoints, yet this is the next paragraph, his conclusion:

So what is my take-home message? The decision should be left in the hands of the family. Current medical evidence points to some specific advantages to being circumcised, especially in certain higher risk groups. In Canada I’m not convinced that there is sufficient medical evidence to advocate for circumcision in a family that would not choose it for religious/cultural/family reasons. Nevertheless in those who do choose it, I think they should be allowed the right to proceed, but I will put in a plea for encouraging adequate pain relief. Let’s face it: None of us would dream of having any procedure on this rather sensitive part of our anatomy without it.

He can’t evaluate the validity of individual autonomy for a human being, but he’s qualified to draw a conclusion without concern for the effect on his conclusion from the ethical claim he did not test. That’s pathetic. It isn’t acceptable to punt an aspect of the debate and then claim victory. It’s more ridiculous because he felt competent to draw an ethical conclusion on pain relief. It’s a minor distance from a plea to use pain relief to a plea to refrain from medically-unnecessary circumcision.

**********

In a paragraph aimed at defending parental choice because a study claims the complication rate is lower for newborns, he wrote:

… My interpretation of this data is that when circumcision is performed by adequately trained individuals, complications are infrequent and usually fairly minor. Most common would be infection and bleeding which can be treated quite easily. Nevertheless severe complications such as penile injury can occur, albeit very rarely. If one wants one’s son circumcised then it appears to be much safer if done in the newborn period.

Penile injury occurs in every single circumcision. Less severe penile injury isn’t irrelevant simply because it was intended.

As if.

Of all the mentions about actress Alicia Silverstone revealing that she and her husband, Christopher Jarecki, did not circumcise their son, I’m fascinated by this one. Anthony Weiss writes:

In her new parenting book, “The Kind Mama,” Silverstone announces that she did not circumcise her son, Bear Blu, according to the anti-circumcision website Beyond the Bris. Her decision apparently raised some family hackles.

“I was raised Jewish, so the second my parents found out that they had a male grandchild, they wanted to know when we’d be having a bris (the Jewish circumcision ceremony traditionally performed 8 days after a baby is born),” she wrote, according to Beyond the Bris. “When I said we weren’t having one, my dad got a bit worked up. But my thinking was: If little boys were supposed to have their penises ‘fixed,’ did that mean we were saying that God made the body imperfect?”

Obviously I’m inclined to agree with that. I probably need to finally write my long-promised post on religion, but for now, I think her statement works consistently within the framework I and many others posit. Non-therapeutic circumcision isn’t something that parents should impose on their sons. Good for her.

That’s not really the interesting part, though.

Her stance sets her in opposition to recent scientific evidence, which indicates that neonatal male circumcision can have substantial health benefits that significantly outweigh the risks.

Her stance does not put her in opposition to scientific evidence, recent or otherwise, about the potential benefits of circumcision. Her stance puts her in agreement with the ethical principle involved. The subset of scientific evidence¹ presented by Prof. Morris’ paper does not prove anything about the application of that subset of scientific evidence to a healthy (hey, science!) child who can’t consent. I don’t have to deny the science to reject its unethical application. Science and the application of science to human beings are not the same concept.

Think of this in terms of Angelina Jolie’s voluntary double mastectomy. Because she carries the BRCA1 gene, the scientific evidence suggests she has a higher risk of developing breast cancer, significantly higher than the absolute risks of a foreskin-related malady requiring circumcision. She judged this evidence and applied it to herself. There is no ethical problem there. But should she apply that scientific evidence to the bodies of her daughters? Mr. Weiss’ approach would require us to conclude that Ms. Jolie not having her daughters’ breasts removed is in opposition to scientific evidence. That’s indefensible even if we restrict it to her daughers who carry the BRCA1 gene. There’s no reason to understand the flaw in Ms. Jolie’s case but pretend the claim is reasonable for non-therapeutic infant circumcision. Proxy consent for the application of science is not the same as consent for the application of science to one’s self.

Also, if you follow the link to Mr. Weiss’ reporting on the recent Brian Morris rehash, you won’t find a coherent argument. Instead you’ll see another example of what I criticized about the journalistic treatment of circumcision. The paper’s focus is the declining circumcision rate. The unsupported “benefits outweigh the risks” is tacked on to criticize that decline. Of course, the paper does not prove that contention about benefits and risks, as Robert Darby and Hugh Young deftly demonstrate. But Mr. Weiss floats around the narrative in a way that makes me think he didn’t read Prof. Morris’ paper.

Darby and Young’s paper also hit on the truth that the “benefits outweigh the risks” narrative persists through assigning no value to the foreskin itself, and by claiming a mathematical finding (i.e. 100 to 1) where no quantification is possible.

¹ Condoms, soap, antibiotics, and other less-invasive methods of prevention and treatment involve scientific evidence, as well. Nor should anything here be taken as an endorsement of the accuracy of anything Prof. Morris has written, anywhere, except for this:

“… Delay puts the child’s health at risk and will usually mean [circumcision] will never happen.”

That statement is true, which discredits everything else he’s ever said in favor of non-therapeutic child circumcision.

**********

The rest of Mr. Weiss’ article discusses Ms. Silverstone’s stances on vaccinations and diet in an attempt to make her appear wrong on circumcision. I’ll only comment that I support vaccination.

Another Reminder

When public health officials advocate for voluntary adult male circumcision, they never mean voluntary or adult. From Zimbabwe:

The ministry was working together with the Population Services International (PSI) on the programme.

PSI director for voluntary medical male circumcision Ngonidzashe Madidi said for the purposes of sustainability, they were studying the early infant male circumcision (EIMC) to ensure protective effect of male circumcision is sustained.

Madidi said they wanted EIMC to run parallel with the adult Voluntary Medical Male Circumcision (VMMC) programme.

“Currently, EIMC is in a study phase and we are happy to say we managed to circumcise at least 560 babies successfully,” Madidi said.

Are the infants happy? Do they think it was successful?

Journalists Doing Brian Morris Undeserved Favors

It isn’t difficult to see how Brian Morris’ process works. He publishes a “new” paper making bold, biased, often-unsupported claims citing his prior work doing the same, and receives circulation for his ideas from unquestioning journalists acting as stenographers. His latest, with Stefan Bailis and Thomas Wiswell, is a good opportunity to assess the reporting within consideration of an excellent article by Ian Sample, “How to write a science news story based on a research paper“.

1. Find a good paper

That rules out anything written by Professor Morris, but I’ll grant that his focus on non-therapeutic infant male circumcision satisfies the criteria that the work be “controversial”.

2. Read it

You cannot cover a paper properly without reading it. The abstract [ed. note: Or the press release] will give the barest essentials. You need to read the introduction for context, the discussion and conclusions for take-home messages. Check the methods. Was the experiment well designed? Was it large enough to draw conclusions from? Find weaknesses and flaws. You will probably need help to work out how fatal they are. Spend time on the results. Have the authors omitted key data? Look at odds ratios, error bars, fitted curves and statistical significances. Are the results robust? Do they back up the scientists’ conclusions? …

Given that Morris’ latest paper is only 10 pages (pdf), including references, this shouldn’t be hard. Yet, I found no initial article covering it that suggested the reporter bothered to read beyond the press release, or perhaps the abstract. For example, both of these articles cite the “benefits exceed risks by at least 100 to 1” line as truth, despite there being no support within the paper for this preposterous claim. It’s merely a statement. Where is the support for this in the paper? The questions Mr. Sample suggest provide a path for investigating this paper further. There is a table of potential benefits cited for circumcision, but no data offering how these are weighted to produce an objective mathematical conclusion.

Within the key table listing claimed benefits, Table 4, Morris cites a study by Dr. Jonathan Wright while omitting the necessary qualification that the study found a correlation, not a causal link. As Dr. Wright stated, “‘These data suggest a biologically plausible mechanism through which circumcision may decrease the risk of prostate cancer,'” said study researcher Dr. Jonathan Wright, an assistant professor of urology at the University of Washington School of Medicine. He noted that the study was observational; it did not show a cause-and-effect link.” How much does this correlation contribute to the “100 to 1” number?

4. Get context

Science builds on science. Know the previous studies that matter so you can paint a fuller picture. …

Like Dr. Wright’s study, for example. Or the way Morris previously used a study by Dr. Kimberly Payne to support a claim that the “highest-quality studies suggest that medical male circumcision has no adverse effect on sexual function, sensitivity, sexual sensation, or satisfaction.” Yet, Dr. Payne’s study, which Morris (and Krieger) rated as the highest quality, resulted in Dr. Payne stating that “[i]t is possible that the uncircumcised penis is more sensitive due to the presence of additional sensory receptors on the prepuce and frenulum, but this cannot be compared with the absence of such structures in the circumcised penis.”

5. Interview the authors
…

Get them to explain their results and justify their conclusions. What do the results mean in plain English? What do they not mean? Ask your questions in simple language to get answers you can quote. Run phrases you might use past the authors, so they can warn you of howlers. Do not ask multi-part questions: you will not get full answers.
…

Perhaps Morris should justify making up rights when he says “[d]enial of infant male circumcision is denial of his rights to good health, something that all responsible parents should consider carefully”. Do parents who do not circumcise their healthy son violate his rights?

This is especially interesting in light of a comment in the press release. Professor Morris said (emphasis added):

“The new findings now show that infant circumcision should be regarded as equivalent to childhood vaccination and that as such it would be unethical not to routinely offer parents circumcision for their baby boy. Delay puts the child’s health at risk and will usually mean it will never happen.“

If not circumcising an infant male “will usually mean it will never happen”, that demonstrates that circumcision will usually not be necessary. Is this one surgery, and the ethical implication, somehow different than withholding from a healthy child every other surgery that will usually never be required?

This also shows the sleight-of-hand in “half of uncircumcised males will require treatment for a medical condition associated with retention of the foreskin,” which is included in the paper (and on Morris’ site). Requiring treatment is not the same as requiring circumcision.

In footnote e of Table 4, Morris cites a figure for risks associated with neonatal circumcision where “data show that risk of an easily treatable condition is approximately 1 in 200 and of a serious complication is 1 in 5000”. So, a complication is not an argument against non-therapeutic infant male circumcision because it will probably be easily treatable. And treatable medical conditions associated with the foreskin will usually not require circumcision, as Professor Morris states, but somehow also justify non-therapeutic infant male circumcision. That’s “Heads I win/Tails you lose” nonsense. Professor Morris is engaging in propaganda.

When the New York Times quoted Morris about this paper, he said: “Just as there are opponents of vaccination, there are opponents of circumcision. But their arguments are emotional and unscientific, and should be disregarded.” That is demagoguery, and should reflect on Professor Morris’ reputation. The argument against non-therapeutic infant male circumcision is rooted in ethics, but it is also rooted in the science of normal human anatomy. The foreskin is healthy, just as every other body part usually is. And opponents of non-therapeutic child circumcision support condoms, soap, and antibiotics, for example, which are all scientific inventions and discoveries.

6. Get other scientists’ opinions

Such as Professor Kevin Pringle, of New Zealand, and Dr. Russell Saunders, pen name for a New England pediatrician. While I disagree with the latter’s conclusion on parental choice, for my purpose in this post, he wrote: “Having reviewed Dr. Morris’s study, I find his statements about the benefits of circumcision as a routine procedure overblown, and the comparison with vaccination baseless.”

7. Find the top line

How about this, from page 7 of the paper:

The timing of circumcision is crucial. Medical and practical considerations strongly favor the neonatal period (Table 4).16 Surgical risk is, thereby, minimized and the accumulated health benefits are maximized.14,16 …

As Morris’ statement about the likely lack of need demonstrates, circumcising in infancy is not usually crucial for the male’s health to the point of circumcision becoming necessary. There isn’t a justification for non-therapeutic infant circumcision. It can wait until the male can choose – or reject – non-therapeutic circumcision for himself.

8. Remember whom you are writing for

This is where Morris gets what he needs most. The headlines encourage readers who only skim headlines to believe that Morris has proven that the potential benefits exceed the risks 100 to 1, that circumcision is similar to a vaccine, and that there is some case for mandatory circumcision of infants. It’s all absurd and does a significant disservice to readers and truth.

9. Be right

Ahem.

The Equation Is Unnecessary Genital Cutting Minus Consent

Many have heaped scorn on Mary Elizabeth Williams’ Salon piece that criticized Alan Cumming for calling male circumcision genital mutilation and comparing it to female genital mutilation. This scorn is deserved.

Alan Cumming wants to tell you about his penis. He wants it to be a shining example to the world. In a candid interview with Drew Grant this week in the New York Observer, the 49-year-old Scottish actor reveals his strong opinions on “Girls,” naughty cellphone pictures, and, most controversially, circumcision. Or as he puts it, “genital mutilation.”

“There’s a double-standard, which is that we condemn the people who cut off girls’ clitorises, but when it happens to boys,” Cumming says. “I mean, it is the most sensitive part of their bodies, it has loads of nerve endings, and it can go horribly wrong. I’m speaking out against it … I’m just so suspicious of the medical industry, which just flings pills at people to ensure everyone is reliant on things. ‘Here are some pills, Mommy. Take them, and we’ll take your baby away and hack its thing off, and then we’ll bill you for that too.’”

I don’t share Mr. Cumming’s view of the medical industry. Its complicity strikes me as cultural inertia and cowardice. My experience suggests that profit-driven focus on circumcision is limited, although it motivates some. But that’s a distraction. The key is that he is correct about the comparison.

Circumcision of a healthy male minor is mutilation of that male’s genitals. To be valid, it must involve his consent prior to the surgery, not assumed to be later granted retroactively. This is the standard inherent in 18 USCS § 116, which criminalizes all non-therapeutic genital cutting on female minors without regard for parental justifications or potential benefits. The difference we imagine is an accident in the history of Western child genital cutting.

Later in the essay:

… And earlier this week, protesters threatened to disrupt Bill and Melinda Gates’ TED Vancouver talk because of their organization’s efforts to increase the practice in Africa as a means of “limiting the spread of HIV in the parts of Sub-Saharan Africa.”

There is good reason to find the work of the Gates Foundation repugnant, as it pertains to male circumcision. It speaks in the euphemism of voluntary medical male circumcision, when it also means infant circumcision. This is unethical because it violates the principles of bodily integrity and consent. And this study, commissioned and funded by the Gates Foundation, hardly provides reassurance when examining the context of WHO and UNAIDS, who think violating this human right of male children can be legitimized through question begging. Mental gymnastics like that are not admirable.

Cumming’s equation of circumcision with female genital mutilation is an insultingly inaccurate one — boys are not circumcised as a ritualized means of suppressing their future sexual enjoyment,

Although it’s easy to find similar defenses of male circumcision, ritual or not, this implies that the critical issue is intent rather than outcome. Female genital mutilation, in all its forms, is wrong because the female is mutilated, not because she is mutilated for “bad” reasons. Some reasons given are the same as those for male circumcision. And not all females who were mutilated reject or condemn it. Yet all reasons for surgically altering the healthy genitals of a female minor are still bad. This focuses on the principles and facts involved, not our feelings.

Notice, too, how often erroneous claims like “[t]here is no evidence whatsoever to support the notion that it affects function, sensation or satisfaction” are made about male circumcision, as it’s made with that quote from Williams’ link to reader comments on an article. The statement is wrong on its face because circumcision changes the function. If you change the form, you change the function. The function of the penis, including its structure, should not be lazily defined as “to have sex” or something similarly ridiculous. The foreskin is normal anatomy with functions for the penis and belongs to its owner.

The quote is disputable on sensation, considering the (anecdotal) arguments in favor of male circumcision stating that males can “last longer“. Consider the heads I win/tails you lose efforts of Brian Morris here, as all outcomes are assumed to be favorable to overall satisfaction, even when the studies cited do not involve anything near 100% on the subjective evaluation of satisfaction.

nor does a clean male circumcision compare with the often crude, blunt and unsanitary practice of female genital mutilation.

Those qualifiers obfuscate. What about clean female genital cutting compared with crude, blunt, and unsanitary male circumcision? A sterile surgical environment does not grant legitimacy to a rights violation. Again, the act is what matters. There are degrees of harm possible, but the inevitability of harm requires first priority, whatever the degree.

The World Health Organization calls FGM “a violation of the human rights of girls and women” with consequences that include “severe pain, shock, hemorrhage (bleeding), tetanus or sepsis (bacterial infection), urine retention, open sores in the genital region and injury to nearby genital tissue,” while it in contrast notes, “There is compelling evidence that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%.”

WHO also explains that female genital mutilation “comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.” There is no unethical caveat for “but if we find some benefits to female health, or even male health, we’d have to weigh mutilating injury against potential benefits.” That unethical caveat is always applied to male genital mutilation, as Williams does here. An adult male volunteering is not the same as an infant male being volunteered. Consent is the issue, not how horrible female genital mutilation usually is or how innocuous and/or beneficial male circumcision appears to be. Non-therapeutic genital cutting on a healthy individual who does not consent is unethical. It involves harm. Gender is irrelevant to the principle.

One can argue, quite persuasively, about whether the practice of circumcision still has validity here in the West, especially among those who don’t have a religious directive. What’s needed, however, is education and enlightenment, so families can make the healthiest choices for their children. …

I reject the premise. This is a not a decision parents should be allowed to make for their children. The argument that parents may decide this for their healthy children requires this decision to be a parental right. If it’s a parental right, then the prohibition of non-therapeutic genital cutting on daughters is indefensible. The basis for thinking about genital cutting can’t be girls and the parents of boys. That’s absurd.

… It’s not helpful to make far-fetched comparisons, and it certainly isn’t constructive to imply that men and boys who are circumcised are somehow damaged, “mutilated” goods. That’s a shaming technique that serves no one, one that turns having a foreskin into a bragging point. …

Why are we only worried about shaming men and boys by using the term “mutilation”? Isn’t there the possibility or likelihood that women and girls will feel shamed if we describe their genitals as mutilated? Are the psyches of females more able to handle facts?

There is a difference in stating a fact and demanding a value judgment from that fact. The bodies of males who were circumcised as children were mutilated. Their rights were violated. Circumcised males are not obligated to think this is bad or shameful. The obligation (for everyone) rests in understanding that it is unacceptable to perpetuate this violation on their children or to permit its continued practice in society.

Or to put it in terms of individual autonomy, circumcision mutilated me through the deprivation of an essential¹ part of my body. Where I had a normal human foreskin, I now have only scars. My penis is mutilated. No one gets to reject that fact for me. But I do not feel shame. This sense that males might feel shame is what encourages parents to circumcise their sons for conformity. We have to stop being afraid of shame. We’ll achieve that only when we are no longer afraid to state that shame belongs with those who circumcise, not those who are circumcised.

… And it’s an unfair judgment coming from a man who admits, “I myself don’t have kids. I just have managers, assistants, agents and publicists.”

I feel second-hand embarrassment, so that at least someone feels what her statement deserves.

¹ Quibble with essential as something other than an obvious stand-in for normal, and I’ll roll my eyes and ask if normal parts of female genitalia are essential.

Brian Earp Confronts the Genital Cutting Double Standard

I’ve discussed the comparison between male circumcision and female genital cutting/mutilation in depth across various posts. In a great post, titled Female genital mutilation (FGM) and male circumcision: time to confront the double standard, Brian Earp discusses the principled comparison in a single post that should become the “Go To” link. It’s worth the read because it’s so thorough and sourced. I know there are people who will read that and remain unconvinced. That is not because the proof isn’t there. He demonstrates the complexity that dismisses the “FGM is always the worst extreme/male circumcision is always the best extreme” that perpetuates superficial thinking on the principled comparison.

Again, it’s all worth reading, but I like this the best (links in original):

So what are the implications here? Given that both male and female forms of genital cutting express different cultural norms depending upon the context, and are performed for different reasons in different cultures, and even in different communities or individual families, how are we meant to assess the permissibility of either one? Do we need to interview each set of parents to make sure that their intended act of cutting is intended as an expression of acceptable norms? If they promise that it isn’t about “sexual control” in their specific case, but rather about “hygiene” or “aesthetics” or something less symbolically problematic, should they be permitted to go ahead? But this is bound to fail. Every parent who requests a genital-altering surgery for their child – for whatever reason under the sun – thinks that they are acting in the child’s best interests; no one thinks that they are “mutilating” their own offspring. Thus it is not the reason for the intervention that determines its permissibility, but rather the consequences of the intervention for the person whose genitals are actually on the line. …

That’s the truth missing from society’s moral relativism. One is judged on outcome alone, with intent assumed from the outcome. The other is judged on intent alone, with outcome assumed from the intent¹. For female genital cutting we focus on the female. For male genital cutting we focus on the parents. That’s the mistake. Separate approaches for the same inherent violation – non-therapeutic genital cutting on a non-consenting individual – cannot hold under inspection. Earp’s post is great for revealing that error with such clarity.

¹ This is especially maddening because the intent we assume and praise is not benign.

Flawed Circumcision Defense: Yair Rosenberg, Part 3

It won’t come as a surprise to read that I don’t think much of Yair Rosenberg’s lazy approach to analyzing non-therapeutic infant male circumcision. Add another example. This time he’s misreporting the findings of another meta-analysis by Brian Morris. Mr. Rosenberg quotes from a Daily Mail article that amounts to little more than a press release.

But first his introduction:

Across Europe, pushes to ban circumcision have rested on its supposedly deleterious effects on a child’s body, and lack of demonstrable benefits. Anne Lindboe, Sweden’s child welfare adviser, has gone so far as to label the practice “violence against children,” claiming that parents who perform it do so out of “ignorance.” She and her counterparts in Denmark and Finland have classified child circumcision as a “human rights violation” and called for it to be criminalized. A German court similarly banned the procedure on the grounds that it caused “bodily harm.” The only problem with these stances? They completely contradict everything science has found about circumcision’s impact on children’s health.

Findings of potential benefits from voluntary, adult male circumcision do not contradict the ethical, rights-based position against non-therapeutic infant male circumcision. Proxy consent is not the same as the consent given by adult volunteers to this permanent, irreversible surgery. Circumcising healthy minors violates their rights to bodily autonomy and integrity, just as any other permanent, non-therapeutic intervention is a violation. It’s the same principle that applies to even the tiniest, less-invasive-than-male-circumcision cut on a female minor’s genitals, which we’ve rightly criminalized. Potential benefits and human rights violation are not mutually exclusive. The presence of potential benefits does not eliminate the fatal ethical flaw. Nor does deciding that circumcision diminishing sexual function, sensitivity, or satisfaction is a “myth”, as Mr. Rosenberg claims of the new meta-analysis by Prof. Morris and Dr. John Krieger.

With that misguided frame, Mr. Rosenberg presents the study:

“The highest-quality studies suggest that medical male circumcision has no adverse effect on sexual function, sensitivity, sexual sensation, or satisfaction,” Professor Brian Morris told The Daily Mail. Morris and his co-author looked at 36 studies covering 40,473 men, half circumcised and half not. They ranked each in terms of scientific rigor and quality, according to accepted official guidelines. And they found that circumcision “had no overall adverse effect on penile sensitivity, sexual arousal, sexual sensation, erectile function, premature ejaculation, duration of intercourse, orgasm difficulties, sexual satisfaction, pleasure, or pain during penetration.” Indeed, after 24 months, 99.9 percent of men were satisfied with their circumcisions–and 72 percent said sensitivity had increased.

There’s a lot to unpack there. The largest point is that Mr. Rosenberg clearly didn’t read the 12 page paper because he regurgitates the results in the digestible (i.e. misleading) package given in the news article. Reading it might reduce his confirmation bias. There are enough obvious limitations, as well:

While the review considered a large body of evidence, there are some factors that may be influencing the findings.

For example, many studies were surveys, and the recruitment process for them is not described. It could be the case that men who have a satisfying sex life may be more willing to participate and answer questions on sexual performance and satisfaction that those who aren’t.

Also, most of the responses in the study are subjective, and what one person considers to be a sexual problem or sexual satisfaction, another might not. There may also be differences in the culture and ethnicity of the participants of certain studies, meaning that their findings cannot be so easily transferred elsewhere.

Beyond that, focus on the conclusion from the study. They state that their analysis suggests this conclusion. Suggests is not a synonym for proves. Yet, even though the Daily Mail article doesn’t use the word in quoting Morris, Mr. Rosenberg states:

Morris told The Daily Mail that he saw his study disproving circumcision’s adverse effects as complementary to those showing its benefits. …

He repeatedly misses the critical issue of consent versus force. In a previous article Mr. Rosenberg summarized a finding that “[i]t would have been unethical to continue without offering circumcision” to the remaining intact volunteers in a study with a simple statement that it would be “[u]nethical not to circumcise the men.” It appears that Mr. Rosenberg is not a reliable filter for news pertaining to circumcision.

There are obvious problems in the current meta-analysis. I will accept their methodology and reasoning as presented, which lead to their “suggests” conclusion. Assuming it is accurate, so what? The findings were not 100%. Of course, 99.9% is presented as essentially the same thing, which is even better than the result we’d expect from a dictator’s latest popular election. From the Krieger et al. Adult Male Circumcision study in Kenya [15]¹, 8.9% of circumcised men identified their penile sexual sensation as something other than “increased” or “the same” 24 months after circumcision. It’s ridiculous to pretend that these men don’t matter and that their experience should be ignored to allow a perceived universal defense for circumcising male minors.

Mr. Rosenberg concludes:

Yet the findings of science have done little thus far to deter Europeans politicians and health officials from seeking to criminalize circumcision, and labeling those who practice it “ignorant” and “barbaric.” It remains to be seen if this study will alter their course.

A utilitarian defense for violating human rights is ineffectual because the defense relies on using only a preferred subset of factors to reach a conclusion. “It’s mine” is a sufficient reason for a male to want his foreskin. He owns his foreskin as much as he owns any other part of his anatomy. Potential benefits valued by his parents are irrelevant while his body is healthy. Proxy consent for this non-therapeutic intervention is invalid because the net benefit or harm is subjective to the individual himself.

This is obvious if considering the question Morris and Krieger asked. Does male circumcision affect sexual function, sensitivity or satisfaction? In order, yes, maybe, and maybe. The findings suggest as much if we look at the participants in the included studies as individuals with their own unique tastes and preferences rather than as statistics. The paper’s focus is sex as a measurable number, which is an idiotic way to reach a conclusion about a subjective topic like human sexuality.

For sexual function, the foreskin is removed. That changes function. Maybe that’s “good”, maybe it’s “bad”. Each person must decide before circumcision what he thinks he wants. What his parents prefer is meaningless.

As for sensitivity, the results are equivocal. I’m willing to accept the negative findings as lower-quality studies for this purpose. But in a study Morris and Krieger rate as 2++, Payne et al [12], this:

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

Yet, for Morris and Krieger, this is support for their “suggests” conclusion because:

… More circumcised participants reported an increase in their level of sexual arousal, while more uncircumcised men reported being unaffected by the erotic stimulus. …

They want to believe, so they believe. That’s the only way I can reconcile the source study with their analysis.

In certain aspects sensitivity is quantifiable, but there is a an element of experience to human sexuality that a generalized “yes” or “no” here dismisses. That same element of experience, but without the ability to quantify in a utilitarian summary, exists in personal evaluations of satisfaction. This is why I don’t state that someone is wrong for preferring circumcision or believing it improves their experience of sex or life, in general. But that is also why it’s wrong for Morris, Krieger, Rosenberg, or anyone else to support parental choice (i.e. proxy consent) for non-therapeutic circumcision. Declaring one’s own preference as a truth applicable to someone else – without concern for the individual’s preference for himself – is the critical mistake inseparable from their argument.

One final point: It’s important to read the abstract and the study rather than just the abstract, even as a layman. Doing so reveals a lot of nuance, as the AAP’s revised position statement in 2012 so embarrassingly showed. It avoids the “It’s official!” conclusion too many (like Mr. Rosenberg here) want to staple to the evolving science involved in circumcision. The Payne [12] study is another example of the importance of this maxim, as are the remaining studies reviewed by Morris and Krieger, probably.

¹ Bracketed numbers correspond to the same-numbered footnote in the Morris/Krieger review.