The Circumcision Decision

You’re having a baby. It’s a joyous event. You’re excited and unsure if you’re up to the task. There will be a lot of on-the-job learning, as well as mistakes that will be more amusing with the passing of time. You’re not supposed to have all the answers, and with experience, it will be clear you can’t plot them all in advance. The discovery is part of the process that makes parenting so exciting and strange and human.

Strangely, we assume parents should make a choice on circumcision if their baby is a boy. Our culture declares that the decision is for the boy’s parents. I’m asking you to make a choice against circumcision because it’s not a choice parents should make for their healthy son(s). Rightly considered, the choice belongs to the individual, not his parents. He should retain his choice absent some medical need for which circumcision – the most radical intervention – is the only available solution.

There are numerous reasons to reject circumcision for your healthy newborn son. The easiest summary comes from a basic principle and an economics concept. First, the principle: non-therapeutic genital cutting on a non-consenting individual is unethical. The problem is not that circumcision is bad, per se. Healthy men who choose to have themselves circumcised are correct for their bodies. Men circumcised as infants who are happy (or indifferent) about being circumcised are also correct for their bodies. But when circumcision is performed on a male without immediate medical need or his consent, there is no guarantee he will be happy with his parents making his choice. That’s the economic concept. All tastes and preferences are subjective and unique to the individual. The boy may like being circumcised, but he may not. It’s impossible to know which a son will prefer.

As the decision is commonly framed in America, circumcision is a referendum on the father’s penis and should be performed on his son if dad is circumcised so that their genitals match. The assumption is that, if it’s good enough for dad, it’s good enough for his sons. However, we know more now than we did when dad was born. We know that circumcision, being surgery, inflicts some guaranteed amount of harm by removing the foreskin and possibly the frenulum, as well as leaving a scar. There is also the possibility of complications inherent in every circumcision. Adhesions, skin bridges, bleeding, infection, greater-than-expected damage to the penis, and worse are all possibilities. Aesthetic symmetry between father and son is insufficient to justify surgery on a child. Rejecting circumcision for a son is sensible, not a referendum on the quality or functionality of his father’s penis.

When those inherent risks are considered, they’re often discussed as a minor trade-off for the potential benefits. The problem is that infant circumcision is almost always non-therapeutic. There is no malady to be resolved, no objective trade-off to be made. Every benefit supposedly in favor of circumcision involves something that might happen or might be desired by the individual. It’s an aggressive intervention on a healthy child whose foreskin will likely remain healthy throughout his life.

Every potential benefit from circumcision can be achieved through less invasive methods that prevent or treat the uncommon ailments cited. Many of these methods, such as condoms, are still required after circumcision. In the unlikely situation where the child eventually requires intervention, a doctor up-to-date on treating an intact penis will still likely be able to resolve a foreskin problem without circumcision. Should circumcision be necessary, he will experience some pain. Leaving him intact does not guarantee that he will eventually experience this pain. Circumcising him when he’s healthy guarantees he will experience pain. The choice is imposing pain that he will feel or exposing him to risk that he might experience pain later. The latter involves pain that he’d likely be able to ameliorate with pain management that an infant can’t have. Even if we assume there is no pain during the procedure, there will be pain during the healing process. Add to that the presence of urine and feces in repeated contact with a healing wound, and the choice to wait until it might be necessary becomes clearer.

For the claimed medical benefits, I accept all of them as possible, even where, for example, I believe there may be flaws in the methodology of the relevant studies. The analysis still leads to the same conclusion if all benefits are assumed to be possible. The details of each matter against circumcision and reveal their flaws. When considered in context, the proposed benefits are weak compared to the availability of prevention methods and treatments both more effective and less invasive than prophylactic circumcision. As Dr. Morten Frisch et al state (pdf), the “cardinal medical question should not be whether circumcision can prevent disease, but how disease can best be prevented.”

To illustrate the weakness of the proposed benefits, consider two commonly cited potential benefits: UTIs and HIV. The benefit for UTIs is a risk reduction from 1 percent of boys in the first year of life to between .1 and .3 percent of boys in the first year of life. Even for the intact boys, this risk is already significantly less than it is for girls. Most UTIs are easily treated without surgery. The same treatments that work for girls also work for boys.

The Canadian Pediatric Society states that, within every 1,000 circumcised boys, two will be admitted to the hospital for a UTI before their first birthday. Within every 1,000 boys left with their foreskins, seven will be admitted to the hospital for a UTI before their first birthday. Factor in the circumcised boys who will need some further treatment for complications, and the risks become clear. Circumcision can cause more problems than it seeks to prevent. As the CPS states, of the 1,000 boys who keep their foreskins, only ten of them “will have a circumcision later in life for medical reasons”. Prophylactic circumcision to avoid a one percent risk of needing that circumcision later is odd.

For the reduced risk of HIV, there are several significant problems related to non-therapeutic child circumcision. This potential benefit has only been found for female-to-male transmission in high-risk populations, and the studies only looked at voluntary, adult circumcision. None of those three aspects describes the situation in the United States or other first world nations. Our sexually transmitted HIV epidemic is male-to-male, and circumcision has not been shown to have any benefit there. Further, the relative risk reduction from circumcision for female-to-male transmission in the U.S. is an estimated 15.7%, far less than the often-cited 60% relevant to Africa. The absolute lifetime risk of HIV infection is already low in the United States. The lifetime absolute risk reduction is small. This summarized table provides the details. And what will science know about preventing or curing HIV by the time a child born today is sexually active?

As stated before, condoms are still necessary after circumcision. Circumcision doesn’t change the male’s required sexual behavior. Parents retain their responsibility to teach him the importance of safe sex practices (and proper hygiene techniques). Nor is there proof that infant circumcision has the same benefits found for voluntary, adult circumcision. Apart from research on UTIs, the potential benefits have been found only in studies using adult volunteers. Despite both being “male circumcision”, the two are not quite the same surgery. The significant difference in consent is most critical, but the foreskin hasn’t separated at birth and must be forced free from the rest of the penis to circumcise an infant. This introduces additional physical trauma and risks for an infant.

The proposed cultural benefits suffer under examination, as well. He has his normal genitals? Women won’t date him, or his peers will make fun of him, the thinking goes. We forget to consider whether he’d prefer his foreskin more than a partner who requires him to be circumcised or if he’ll even encounter a partner who prefers circumcision¹. Parents can build enough self-worth into their children to withstand teasing. That’s essential because children will always find something about their peers to tease. If it’s not his foreskin, it’ll be his height or hair color or clothing or whatever else is easy. Anyway, the locker room fear is rooted in the experiences of prior generations when communal showering was common in schools. It’s best examined in the present rather than holding to a scenario that no longer exists, especially as fewer parents circumcise their sons. Half or more of his peers will be intact. If he is “different”, he’ll be different like many of his peers. As children grow, parents realize their goal is not to teach their child to conform, but rather to help him become an independent person whose differences make him who he is. Making a major, irreversible decision for him before parent and child have grown to that point in their relationship may become something the parent or the child regrets.

The premise of this approach is “I don’t know”. None of us knows. We don’t know what we’ll want in the future. We don’t know what science will discover that makes circumcision even more unnecessary to achieve the possible benefits. We don’t know who we’ll be or who we’ll meet. Not circumcising sons in the absence of medical need prioritizes optimism over unfounded fear. It’s about keeping their choices open until they can express their personal preference about what they want and what will make them happy. It’s a realization that “what if” can be about a good future rather than succumbing to a fear of unlikely dangers.

Your son will be born with a foreskin. His prepuce is normal. It will belong to him, just like every other normal part of his body. It has functions. You want what is best for your children. Your son can always have his foreskin removed later, either for need or choice. He can’t put it back if he wants it after circumcision. Choosing to leave your son intact is the better choice.

¹ Many non-Americans are flabbergasted when they learn that circumcision has been so prevalent in the U.S. Their primary experience is with men who still have their foreskins. Given the declining rate of circumcision, the future American partners of a child born today will likely mirror that acceptance.

The AAP Discounts Its Patients’ Right to Physical Integrity

In “Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision”, Morten Frisch, MD, PhD, et al (pdf) criticize the AAP’s revised policy statement on circumcision. In part, they state:

The most important criteria for the justification of medical procedures are necessity, cost-effectiveness, subsidiarity, proportionality, and consent. For preventive medical procedures, this means that the procedure must effectively lead to the prevention of a serious medical problem, that there is no less intrusive means of reaching the same goal, and that the risks of the procedure are proportional to the intended benefit. In addition, when performed in childhood, it needs to be clearly demonstrated that it is essential to perform the procedure before an age at which the individual can make a decision about the procedure for him or herself.

They raise many issues surrounding the AAP’s focus on UTIs, penile cancer, STDs, and HIV. They conclude that non-therapeutic circumcision “fails to meet the commonly accepted criteria for the justification of preventive medical procedures in children.” Even ignoring their critique of the applicability of the scientific studies involved in the AAP’s revised policy statement, they are convincing. Their ethical argument is powerful.

The response by the AAP’s Task Force on Circumcision is intriguing and bizarre. It’s intriguing because it raises potential issues with what Frisch et al wrote about the science. This section is worth discussing, but not by me. I see the points on both sides. It’s difficult for either to squeeze every helpful detail into a few pages. For this, I’ll leave it with my usual statement. I am willing to accept the claimed benefits, however faulty they may be. The ironclad ethical case against non-therapeutic child circumcision is no weaker if all of the AAP’s criticisms have full merit.

Its response is bizarre for the ethical issues the Task Force continues to dismiss and ignore.

First, responding to the claim that the Task Force suffered from cultural bias:

… Although that heterogeneity may lead to a more tolerant view toward circumcision in the United States than in Europe, the cultural “bias” in the United States is much more likely to be a neutral one than that found in Europe, where there is a clear bias against circumcision. …

That (claimed) neutrality is the problem in the AAP’s revised policy statement on male circumcision. They imagine that there is no right answer to this ethical question. Here, the physical integrity of a healthy child is surgically violated without his consent. The law recognizes a single correct answer for female minors on the same ethical question. The implicit conclusion that male minors possess a lesser right to their physical integrity than their sisters is indefensible. It doesn’t matter that potential benefits exist from circumcision. Frisch et al demonstrate this in analyzing the difference between consent and proxy consent for a non-therapeutic intervention.

The AAP continues its challenge:

… Yet, the commentary’s authors have, at no point, recognized that their own cultural bias may exist in equal, if not greater, measure than any cultural bias that might exist among the members of the AAP Task Force on Circumcision. If cultural bias influences the review of available evidence, then a culture that is comfortable with both the circumcised penis and the uncircumcised penis would seem predisposed to a more dispassionate analysis of the scientific literature than a culture with a bias that is either strongly opposed to circumcision or strongly in favor of it.

So, basically, the AAP’s Task Force is saying “I’m rubber, you’re glue”.

To the point, Frisch et al show that the cultural acceptability of circumcision is not a valid defense because there is a right answer to the ethical question involving this prophylactic surgical intervention on healthy children. The AAP missed the essential issue in its recommendation. The ongoing American experiment with circumcision is a reasonably-inferred explanation. Frisch et al emphasize the child in non-therapeutic child circumcision. The AAP continues to emphasize only circumcision, with the children being a distant abstract. That is the problem, regardless of the reason.

For the purpose of those paragraphs, I pretended that the AAP’s claim that the US is neutral on infant circumcision isn’t laughable nonsense. On the basis of individual opinions, I think we’re probably the fifty-fifty nation they imagine. Institutionally, both medically and politically, we are very much a pro-circumcision nation. The Task Force stated a truth, while missing it, in its Technical Report:

… Reasonable people may disagree, however, as to what is in the best interest of any individual patient or how the potential medical benefits and potential medical harms of circumcision should be weighed against each other. …

The factually-unprovable statement in the Abstract that the “preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure” is the evidence that the AAP is not a pillar of neutrality on non-therapeutic male child circumcision. The Task Force thinks the subjectivity it mistakenly presents as a valid general conclusion in its Abstract may reasonably be taken into consideration for circumcising an individual by proxy consent. If they understood the ethical implications, they would acknowledge that it must only be taken into consideration by the individual for his own healthy body. The neutral position presents facts and lets the individual choose. The biased position lets someone else impose a permanent, unnecessary intervention for the individual.

The Task Force includes a section, Age at Circumcision, in which their argument is that many minors make their sexual debut before the age of majority and some of those people are irresponsible with regard to condoms. The Task Force argues these two facts render it acceptable for parents to make their son’s circumcision decision for him. It views parents through an ideal, rather than the reality of human decision-making where a child must live with the permanent consequences of an unnecessary decision. Individuals are just part of a statistic.

When the Task Force finally gets to the ethical issues, it whiffs again:

… The authors’ argument about the basic right to physical integrity is an important one, but it needs to be balanced by other considerations. The right to physical integrity is easier to defend in the context of a procedure that offers no potential benefit, but the assertion by Frisch et al of ‘no benefit’ is clearly contradicted by the published scientific peer-reviewed evidence. …

Because there are potential benefits, we may discard the supremacy of the basic human right to physical integrity for the healthy child? That’s ridiculous. They don’t say it directly, but their conclusion for parents making their son’s choice endorses it in reality. With this thinking, any number of extreme surgical interventions could be justified on a healthy child because they might offer some benefit at some point. We should at least research any possible intervention to make sure we’re not missing some benefit that could decrease some risk, if that really is an acceptable approach. Or we could be rational and set aside our long-held cultural acceptance of this unethical procedure, but that’s harder to defend than fear, I guess.

The second statement, the “assertion by Frisch et al of ‘no benefit'”, is not supported by my reading of their paper. They do not state there is ‘no benefit’ to circumcision. They question the strength of the benefits and their applicability to children, particularly because less intrusive methods to achieve these benefits are available. The Task Force builds a straw man instead of confronting the ethical issues.

Finally, the Task Force asserts the “right to grow up circumcised“:

Frisch et al appeal to the ethical precept “First, do no harm,” but they fail to recognize that in situations in which a preventive benefit exists, harm can also be done by failing to act. Whereas there are rare situations in which a male will be harmed by a circumcision procedure, …

I’m interrupting the excerpt to correct this inaccurate statement. Every circumcision inflicts harm, including loss of normal tissue and nerve endings, as well as scarring. Some circumcisions inflict more harm than expected or intended. The Task Force conflates intent and outcome.

… it is also true that some males will be harmed by not being circumcised. Simply because it is difficult to identify exactly which individuals have suffered a harm because they were not circumcised should not lead one to discount the very real harms that might befall some men by not being circumcised. …

I don’t discount the real harms some will experience from the risks in being alive with a normal human anatomy. I dismiss their relevance in this context. It’s a dumb standard for evaluating what may be done to a healthy child without his consent. Life can never be lived without risk. If a male is worried enough about the minimal risks posed by his foreskin, he can elect to be circumcised with his own informed consent. But the reverse is not true. A male who is circumcised at birth can’t recover his foreskin if he would not trade his foreskin¹ for the proposed benefits. Individual choice is the valid, superior ethical position.

Their conclusion:

… There is no easy answer to this issue ethically. Regardless of what decision is made on behalf of a young male, harm might [ed. note: will, if the decision is circumcision] result from that decision. That is precisely why the AAP task force members found that this decision properly remains with parents and that parents should have information about both potential benefits and potential harms as they make this decision for their child.

There is an easy answer to this issue ethically. Non-therapeutic genital cutting on a non-consenting male is unethical. It inflicts guaranteed harm to minimize already tiny risks. This is the same easy answer we draw for females. We know parents shouldn’t make this decision unless it is “necessary to the health of the person on whom it is performed” when the person on whom it is performed is female. We’ve legislated this knowledge. The right to physical integrity is easy to defend. The AAP has an ethical duty to defend it for all children, including males.

¹ Full quote from AAP Task Force on Circumcision member Dr. Douglas Diekema: “[Circumcision] does carry some risk and does involve the loss of the foreskin, which some men are angry about. But it does have medical benefit. Not everyone would trade that foreskin for that medical benefit.”

Genital Mutilation Is One Cause

Owen at Oggy Bloggy Ogwr posted a fascinating discussion on International Women’s Day – Life, Ethics & Independence III – Circumcision. He’s thorough and makes a strong case, summarized with this:

I think the point I’m trying to make here is that perceived injustices that might be deemed “the same cause” for both sexes might not be similar at all. It’s issues like this that mean we have/need an International Women’s Day in the first place.

There are millions of women who currently have to endure some of the worst abuses humankind can throw at them for simply being born the “wrong gender”, and who don’t have much of a voice – except on days like today.

His post is strong because he addresses the issues involved rather than defending International Women’s Day with the rhetorical equivalent of “Shut up, men”. I disagree with very few of his points in the post. However, those few lead me to disagree with his defense of his conclusion, while accepting his conclusion that there is value in addressing the injustices women and girls still face and doing so on their own. Basically, his second paragraph stands without the incorrect qualification presented in the first.

My primary disagreement is here:

Is there a double standard here?

Uh….no.

If female circumcision only ever involved removing the clitoral hood – the female equivalent of a foreskin – and was still deemed “genital mutilation” then you would have a point. I doubt you can compare this with women making an informed and conscious choice to have various “body modifications” either.

The UK and US anti-FGM acts prohibit all non-therapeutic female genital cutting, including that which is analogous or less damaging than male circumcision. They prohibit “procedures that intentionally alter or injure female genital organs for non-medical reasons.” The WHO fact sheet on FGM defines it as “removing and damaging healthy and normal female genital tissue, and interferes with the natural functions of girls’ and women’s bodies.” All non-therapeutic cutting on a female without her consent is (rightly) considered mutilation.

Male circumcision fits within both descriptions above, as well as the definition of mutilation. There is no valid reason to distinguish non-therapeutic genital cutting on a non-consenting individual as mutilation or somehow not. The lack of consent to any level of permanent, non-therapeutic surgical harm is the critical issue in identifying genital mutilation. Male circumcision or hoodectomy or any other non-therapeutic cutting is ethically acceptable only when voluntarily chosen by the individual receiving it. Proxy consent is still lack of consent.

I recognize the often great difference in severity from what is typically done to males and females. That matters, and should inform penalties, whether criminal or civil. This difference should not inform legality. (The challenge of enforceability can’t be ignored, of course, but that’s separate from what “should be”.) As I’ve said before, a punch to the face is still battery even though a knife to the gut generally causes more damage.

To be fair, Owen made it clear that he understands the problem inherent in male circumcision. He disagrees with imposing it on children. I am not saying anyone needs to fight male circumcision in their fight against FGM, even though they are the same cause in principle. My point is that FGM is bad enough on its own that making that case doesn’t need a separation of male circumcision from mutilation. This is also true because separating male circumcision from mutilation is counter-factual.

(Conversely, the case against male circumcision can be made without a comparison to FGM.)

Dr. Douglas Diekema: Still Inconsistent on Circumcision

Inevitably, whenever a new study suggests that circumcision may not be a panacea of benefits without costs, dismissal follows swiftly. That isn’t the problem. Skepticism is always warranted, and sometimes, criticism is also warranted. I do wish more people, particularly journalists, would adhere to that when pro-circumcision studies are published, but c’est la vie. The facts are on our side in this (unfortunately) long effort. The key is getting to facts.

With the recent study confirming “the importance of the foreskin for penile sensitivity, overall sexual satisfaction, and penile functioning”, the refutations have begun. When Dr. Douglas Diekema criticizes, odd bouts of cognitive dissonance are almost guaranteed. Here, Dr. Diekema joins the rebuttal¹ to this study with his unique way of missing a much-needed chance for self-examination.

“The study is pretty flawed,” said Douglas Diekema, a pediatrics professor at the University of Washington, who was part of the American Academy of Pediatrics 2012 task force on circumcision. “I read the conclusion and then I read the study, and I said, ‘Wow, they went overboard in what they’re concluding.'”

If only Dr. Diekema, a member of the American Academy of Pediatrics (AAP) Task Force on Circumcision, always cared about having the details match the conclusion, with not going overboard in a conclusion. For example, in the AAP’s revised policy statement on circumcision, the technical report states (page 759):

… Reasonable people may disagree, however, as to what is in the best interest of any individual patient or how the potential medical benefits and potential medical harms of circumcision should be weighed against each other. …

That’s the core truth for any non-therapeutic intervention, which clarifies the ethical flaw in proxy consent for non-therapeutic circumcision. What does the individual who doesn’t need circumcision want for himself?

Yet, in the abstract for its revised policy, the AAP bizarrely concludes:

Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; …

The statements in the technical report and the abstract do not say the same thing. The details do not support the conclusion. The abstract states an opinion that the technical report makes clear is not universally true or applicable to any specific individual male. Dr. Diekema once stated (correctly) that “not everyone would trade that foreskin for that medical benefit.” Yet, he stands behind the revised policy that encourages proxy consent for non-therapeutic circumcision while maligns those who criticize the report for its obvious flaws. He’s made these contradictory statements for more than a year. At some point maybe he’ll stop doing that, or he could even embrace the ethics involved that require rejecting non-therapeutic genital cutting on a non-consenting child. I can hope.

¹ The study may be flawed, and perhaps in exactly the way Dr. Diekema states. I don’t wish to engage in confirmation bias merely because I like the findings. Anyway, I don’t need the study. The principled ethics matter more than whether circumcision is “good” or “bad”, both subjective to the individual foreskin owner.

We Must Do Better

There’s a circumcision flowchart floating around that needs to be addressed. Here it is:

Flowchart1_resized

It fails from the start. The right first question is “Is there a medical problem with the foreskin?”, or something similar. That will get the circumcision decision process started.

“Do you have a penis?” is never a relevant question. It’s a sexist approach that fails to promote the critical, universal genital integrity rights involved. Fathers and mothers are equally capable of offering good and bad arguments on non-therapeutic child circumcision. We must address individuals, not generalizations. The latter leaves us making ineffective arguments to proponents who might be willing to change their mind to protect their son(s).

To put it in perspective, am I not allowed to denounce non-therapeutic female genital cutting because I don’t have labia or a clitoris? The idea is ridiculous. The human rights issue is first. We’re all capable of using our intellect and reason to understand genital integrity. Let’s use them and expect others to do the same.

If we start with awful premises, we interfere with our objective of protecting the bodies and rights of children. If we promote the idea that some people are inferior, they will tune us out when we state that all people should be treated equally. Please, stop promoting this flowchart. We can be better than this. We must be.

P.S. Shut up also needs to go.

Ghana Encourages Unethical Infant Circumcision

As always, when public health officials endorse voluntary, adult male circumcision to reduce the risk of (female-to-male) HIV transmission, they never mean voluntary or adult. Today, Ghana:

Dr Gloria Asare, a Public Health Consultant, has said male circumcision was one key area of HIV and AIDS prevention and appealed to families to circumcise their male children.

Someday we won’t let good intentions and fear blind us to the fatal ethical flaw within non-therapeutic infant circumcision. We will endorse and require consent from the patient rather than proxy consent for the patient.

Dr Limakatso Lebina’s Ridiculous Circumcision Euphemism

Anyone familiar with the way voluntary, adult male circumcision is being promoted as a way to reduce the risk of female-to-male HIV transmission in high-risk populations already knows how it’s promoted. The brochure excludes context-specific qualifiers. That mouthful in the first sentence is always shortened to “circumcision reduces the risk of HIV”, even though that broad statement isn’t supported by the studies. In addition, voluntary, adult male circumcision loses words over time. Adult was the first word to go. Voluntary is still used, but that word doesn’t mean what it’s used to represent. Consent must only come from the patient when the circumcision is non-therapeutic. Absent that consent, the surgery shouldn’t be imposed on a healthy minor. In a discrediting move, no one adheres to that. It took six days from the 2006 release of the major HIV study on voluntary, adult circumcision in Africa for the U.N. to propose targeting infants first among all males in HIV-ravaged parts of Africa. Perpetuating circumcision via physical indoctrination is the new standard. Voluntary disappeared a long time ago as anything more than a marketing word.

I do not wish to suggest I think this is a conspiracy. Public health officials believe they are acting nobly. A well-meaning focus on one’s own preferences explains this at least as well. We must do something to reduce HIV. Circumcision is something. Therefore, we should circumcise. That’s bad logic, and relies too heavily on the nonsensical idea that someone happy with being circumcised proves everyone will be happy being circumcised. It treats the individual as a tool to achieve some public goal. That’s mistaken but it seems rooted in good intentions.

Now, knowing all of this, I’m difficult to surprise with how public health officials promote circumcision. I expect dumb, offensive strategies. I still can’t believe this from the opening of a new circumcision clinic at Tshepong Hospital in Klerksdorp, South Africa:

The clinic is called Gola Monna, or “Grow up Man” in Setswana. Its founder, Dr Limakatso Lebina, said: “This clinic will circumcise men and will ensure that they have lifelong partial protection against HIV.

“The removal of the foreskin clearly can’t stop all HIV infections but it certainly prevents most. [ed. note: dangerous misinformation] We tell all the men that we circumcise that they must continue to condomise,” she said.

Asked why women should be included, Dr Lebina explained: “Women should be involved in decisions about getting a safe circumcision. As mothers of boys and partners of men, they must ensure that the males in their lives are protected from HIV”

A quick pause to note how easily both adult and voluntary are missing as concepts in Dr. Lebina’s approach. This is more curious because MEC Dr. Magome Masike said that “communities must encourage men aged from 15 to 45 to come to this new clinic for circumcision.” A newborn male is not a man.

This, though, is absurd and offensive:

She added: “There is data to show women prefer circumcised men.[¹] So take a Valentine’s day decision to get a love cut and come in for male circumcision at the clinic.”

Rather than “voluntary” male circumcision, we have a “love cut”. This is no different than asking opponents “why do you want people to get HIV?,” as if one can’t be opposed to both non-voluntary forced circumcision and the transmission of HIV. Here, Dr. Lebina implies that an intact man who won’t have himself circumcised doesn’t love his partner as much as someone who would have himself circumcised. It’s preposterous. It also encourages parents to circumcise their sons because they love them. That’s twisted. Circumcision is not a gift.

Public policy needs to return to voluntary, adult male circumcision and mean it. Euphemisms like this, however well-intentioned, are Orwellian distortions that hide the ethical issues from those promoting and from those deciding on circumcision.

¹ The standard “women prefer circumcised men” is as expected here as it is irrelevant. Women (and men) are entitled to prefer whatever they want from a partner. They are not entitled to have it. What a partner prefers does not require a person to agree to have it done. Preference does not excuse imposing it on an individual in response to or as speculation about what a current or future partner prefers about his genitals.

International Day of Zero Tolerance to FGM, 2013

Today is International Day of Zero Tolerance to Female Genital Mutilation. The WHO statement on this is lacking, which I don’t find surprising. (emphasis added)

The International Day of Zero Tolerance to Female Genital Mutilation is observed each year to raise awareness about this practice. Female genital mutilation of any type has been recognized as a harmful practice and violation of the human rights of girls and women. WHO is committed to the elimination of female genital mutilation within a generation and is focusing on advocacy, research and guidance for health professionals and health systems.

Female genital mutilation (FGM) refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons. Female genital mutilation has no known health benefits. On the contrary, it is associated with a series of short and long-term risks to both physical, mental and sexual health and well-being.

FGM is affecting about 140 million girls and women, and more than 3 million girls are at risk every year. A special focus for WHO this year, is the troubling trend of health-care providers increasingly being the ones performing female genital mutilation, and thereby contributing to legitimize and maintain the practice.

Today, I’m not going to discuss the comparison to male circumcision beyond the one inherent in this sentence. I am going to use WHO’s approach to male circumcision to compare why its last sentence shouldn’t be a surprise.

Stating that FGM has no known health benefits works from the premise that the possibility of benefits could justify FGM. No benefit could justify forced FGC (i.e. mutilation). The human rights principle is superior. WHO should state that as its foundation, and be consistent and repetitive. In reminding readers about this lack of benefits, WHO almost apologizes for being against FGM. The absence of benefits is not why this shouldn’t be done.

Think back to when the AAP issued a revised policy statement on FGC, later retracted. As I wrote here and here, I didn’t/don’t think it said what people read into it. But the reaction was universal and swift. On the idea that permitting limited forms of genital cutting could prevent greater harm to females, activists stood on the absolute principle. Whether or not this makes sense is a worthwhile discussion. (My posts linked above set out my thoughts on the issue. The principle still matters more.) Regardless, that incident demonstrates that activists would never excuse FGC/M if benefits were proposed or found. Can anyone imagine a scenario where any scientific committee allowed research into possible benefits? For those inclined to accept possible benefits as a justification, everyone else must discourage this thinking. Lazy statements that lack the courage to defends what is morally and ethically correct fail that goal.

WHO’s approach, which informs its stance on male circumcision, enables the predictable problems described in the last sentence. Because the organization refuses to stand for principle where courage is necessary, it creates the conflict of legitimizing genital cutting through “medical” male circumcision programs. I know of no populations that cut females that don’t also cut males. So, WHO drives campaigns to legitimize genital cutting while driving campaigns to delegitimize genital cutting. The flaw is obvious. The principle and consistency matter.

Dumbest Sentence I’ve Read Today

From the Anne Arundel Medical Center’s information page on (infant) circumcision, in the “How is circumcision performed?” section:

Circumcision is performed only on healthy babies.

I will never understand how medical service providers can recognize that and still think nothing is wrong with their participation in their imposition of this non-therapeutic surgery on their patient.

We Were All Female. We Are All Humans.

Here’s a fantastic video from AsapSCIENCE:

It’s an oversimplification, but barely, to say that we all have the same parts. They look different but start as the same. We are equal. There is no reason to imagine that the damage from non-therapeutic cutting of male genitals is acceptable in the way we reject as obvious for any female genital cutting. We all begin with a common foundation. Yes, the intent – and often, extent – can be quite different. We must not forget or ignore that. But that isn’t enough. It’s possible to recognize the rights of boys without minimizing or easing protection against what is done to girls. The issue remains that permanent harm results from non-therapeutic genital cutting.

Society has developed irrational rules that somehow the basic human rights to genital integrity and bodily autonomy splinter after the first six weeks of fetal development. Females maintain this right, but once the Y chromosome becomes dominant, legal and ethical concern for this right inexcusably diminishes among too many. We should not behave this way. The above video demonstrates that this distinction is false. Boys deserve their human rights, too.

Video via Geeks are Sexy.