Author: Tony

Flawed Circumcision Defense: Jesse Bering

“It requires education to see the world through disease-coloured glasses.” – Thomas Szasz (“Circumcision and the birth of the therapeutic state”)

Jesse Bering, PhD, endorses the AAP’s revised policy statement on non-therapeutic male child circumcision. He asks readers to replace the God he doesn’t believe in with the god he does believe in. He starts with some introduction about himself being circumcised, while his partner is intact. He then writes:

Whatever the reasons that previous generations may have had for choosing to remove their infant sons’ foreskins, they were almost always unconvincing. All else being equal – … – all else being equal, any dubious benefits derived from religious, social, hygienic, or aesthetic reasons are clearly outweighed by the costs of male circumcision. …

It might be surprising that I disagree with that. The costs clearly outweigh the benefits for me, then and now. But I do not believe that’s an objective conclusion for everyone. Each person has his own preferences unique to himself. It’s not for me to demand that anyone accept my opinion for myself as a substitute for his own opinion about his body. This involves the individual and his lack of need, and what those two details require for proxy consent.

Today, however, all is no longer equal, and the balance between the relative risks and benefits of male circumcision has clearly shifted in the other direction. That is, it has according to the American Academy of Pediatrics, which just earlier this week put out its revised position statement on infant male circumcision. Here’s the money quote:

Systematic evaluation of English-language peer-reviewed literature from 1995 through 2010 indicates that preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure. Benefits include significant reductions in the risk of urinary tract infection in the first year of life and, subsequently, in the risk of heterosexual acquisition of HIV and the transmission of other sexually transmitted infections.

There is no way for these relative inputs to clearly demonstrate the universal conclusion endorsed by either. The AAP and Bering demand too much. And the money quote is not what Bering provides, but instead this quote from the 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. …

As I wrote earlier, the highlighted statement is the ethical argument. It demonstrates the flaw in pretending that “preventive health benefits of elective circumcision of male newborns outweigh the risks” is an objective conclusion, or that it justifies proxy consent for non-therapeutic male child circumcision. The AAP Task Force stating its evaluation based on its members’ subjective weighting does not change the ethical and rights violation. Individuals – males, only – should not be forced to live with a permanent, non-therapeutic alteration to their bodies based on their parents’ subjective preferences.

… The more vocal “intactivists,” who’ve long been protesting what they regard as an antiquated, cruel and unnecessary ritual act against little boys that is just as abhorrent as female clitoridectomy, have also responded bitterly to this newest AAP development, seeing fresh strands in an ongoing web of conspiracy between the major health organizations, third-party insurance companies implementing the policy views of these organizations, and greedy practitioners who mislead parents about the benefits of circumcision only to reap insurance payouts for “mutilating” children’s genitals.

Even though there are instances of conspiracy thinking, which are inexcusable, this is a straw man. I quoted the key sentence from the AAP’s policy statement above. There are valid issues involved that do not require conspiracy thinking to reject the AAP’s recommendation. Erecting straw men doesn’t negate those issues. For example, bodily harm, physical integrity, self-determination, and equal protection. Something more than weak caricatures of opposing positions would be useful. Engage in an Ideological Turing Test, at least. That would be respectable, unlike “just watch the reactions to this little essay of mine”.

What is vital to understand about the AAP’s recommendation is that the Academy is not discounting, in any way, the biological purpose or function of foreskin. …

I can’t find anything in either the policy statement or the technical report that discusses the biological purpose or function of the foreskin in a manner suggesting someone might want it. I also won’t ignore the implication throughout that parents should be allowed to discount the foreskin in any way they wish for their son(s). That implication is a critical part of the analysis, since that’s where the AAP and Jesse Bering believe this non-therapeutic, unethical decision may be made.

Within the two columns of one page where the Task Force discusses the foreskin, it pursues only the question of whether sensitivity and/or function are altered. That is different than stating advantages of having a foreskin. The abstract merely states: “Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction.” Within those two columns in the Sexual Function and Penile Sexual Sensitivity section on page 769, the technical report is a bit stronger :

The literature review does not support the belief that male circumcision adversely affects penile sexual function or sensitivity, or sexual satisfaction, regardless of how these factors are defined.

The problem is that the literature doesn’t seem to support the belief that male circumcision does not adversely affect penile sexual function or sensitivity, either. (Circumcision always alters the mechanics of the penis.) From the two “good quality randomized controlled trials that evaluated the effect of adult circumcision on sexual satisfaction and sensitivity in Uganda and Kenya” since 1995, the reports were compelling. Except for the caveats:

… [The Ugandan] study included no measures of time to ejaculation or sensory changes on the penis. In the Kenyan study (which had a nearly identical design and similar results), 64% of circumcised men reported much greater penile sensitivity postcircumcision.127 At the 2-year followup, 55% of circumcised men reported having an easier time reaching orgasm than they had precircumcision, although the findings did not reach statistical significance. The studies’ limitation is that the outcomes of interest were subjective, self-reported measures rather than objective measures.

It doesn’t bother me if a male is happy with being circumcised, even if his parents made his decision in childhood. That doesn’t change the ethical issue. I’m questioning the applicability of these studies on adults to newborns. Those limitations are critical. It’s also hardly compelling to imagine that individual preferences should be ignored in favor of population-based opinions. Within every finding in those two studies, there are males who do not conclude that circumcision is neutral or better for themselves.

From the Sexual Function section:

There is both good and fair evidence that sexual function is not adversely affected in circumcised men compared with uncircumcised men.131,134–136 …

Quoting the the study in footnote 136, “Sensation and sexual arousal in circumcised and uncircumcised men”:

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.

Maybe that should’ve been included in the Sexual Satisfaction and Sensitivity section? To restate the obvious: the foreskin is removed during circumcision. Comparing that in circumcised men is impossible. Or, as the technical report states:

Limitations to consider with respect to this issue include the timing of IELT [intravaginal ejaculation latency time] studies after circumcision, because studies of sexual function at 12 weeks postcircumcision by using IELT measures may not accurately reflect sexual function at a later period. …

Studying whether or not adult circumcision adversely affects sexual sensitivity or function does not necessarily answer the same question for males circumcised as infants.

Back to Bering’s post:

… What the task force has implied, rather, is that whatever the advantages to being an intact male – such as increased sensitivity of the glans, protection, lubrication facilitating better heterosexual intercourse (in addition to the lubricating properties of shed skin cells and oils that accumulate under foreskins, an accentuated coronal ridge may also retract more vaginal fluids during copulative thrusting) – these advantages are overshadowed in importance by the prophylactic benefits of removing highly receptive HIV target cells that are found on the inner mucosal surface of the foreskin. …

Did the Task Force consider any of the advantages Bering listed? I didn’t see any of them stated in the policy statement. That suggests to me that the Task Force discounted the foreskin. They don’t appear to have considered the foreskin in any meaningful way. The recommendation that the benefits outweigh the risks is subjective and lacking in universal applicability. They proved no overshadowing.

To quote Task Force member Douglas Diekema, male circumcision “does have medical benefit. Not everyone would trade that foreskin for that medical benefit.” That seems obvious, especially since it’s implied in the ethical issues section of the technical report. That’s what makes it odd to see the nonsensical declaration in the abstract. And from Bering:

To circumcise, or not to circumcise? To me, at least, that’s no longer even a question. It remains as much a no-brainer as it was when I first wrote about this issue two years ago. If male circumcision reduces the probability of contracting the HIV virus even a fraction of a percent—let alone the estimated 60 percent reduction that scientists believe it does—…

From the technical report:

Mathematical modeling by the CDC shows that, taking an average efficacy of 60% from the African trials, and assuming the protective effect of circumcision applies only to heterosexually acquired HIV, there would be a 15.7% reduction in lifetime HIV risk for all males.

I’m aware of no studies showing a reduced risk from circumcision for anything other than female-to-male transmission through vaginal intercourse, so that assumption is perhaps reasonable. (The difference in context between the U.S. and the high epidemic in Africa may reduce the number further.) Thus, the 60 percent relative risk is not the correct number. The estimated 15.7% lifetime relative risk reduction becomes a fraction of a percent reduction in absolute risk of heterosexually acquired HIV in the United States.

… then why on earth wouldn’t you choose circumcision? …

Because the healthy child does not need and may not want to be circumcised? Because he still has to wear a condom? Because there are risks and costs from circumcision? Because not everyone would trade that foreskin for that medical benefit? Because all individual tastes and preferences are unique? That’s why on earth parents shouldn’t choose circumcision for their healthy sons.

In the context of the quote that opens this post:

… Have you ever seen a person slowly succumb to AIDS? The pain inherent therein is not even in the same galaxy of subjective experience as whatever minute qualia of pleasure may or may not be lost to such a “mutilation.” The sacrifice is no longer one made to a mythological deity, but to the child himself. HIV is not just an African problem, the logistics apply to any part of the world where the virus is found, …

Do we know the subjective experience difference is a minute qualia of pleasure? Does the child want that sacrifice made to him? He doesn’t need it and has ways to achieve the same benefit in greater measure.

… and circumcision protects against more than this one virus alone. If you want to invest in the probability that your son will grow up to become so unfailingly logical that lust will never, not even once, overcome his level-headedness, and that he will always have both a condom on hand and use it every single time that an opportunity to have intercourse with a potentially infected stranger arises, that’s your prerogative. You’ve probably not interacted with many actual human beings in your life, but, hey, it’s your kid.

I am so unfailingly logical that lust has never, not even once, overcome my level-headedness. I do not want or need that benefit in exchange for my foreskin, yet I no longer have my choice about my body. But, hey, I’m my parents’ kid. My foreskin belonged to them, so why I should I reject their decision about my body?

One can either listen to …, the overwrought intactivists attempting to intimidate new parents through strong rhetoric and graphic images of botched circumcisions, …

What does “Have you ever seen a person slowly succumb to AIDS?” qualify as, if not strong rhetoric?

What was once unquestionably “inhumane” and “unethical” has, oddly enough, made a complete about-face as a consequence of vitally important scientific data emerging over the brief span of two highly productive decades. Yet many parents continue to be emotionally sabotaged by the baby-harming language of intactivists and online blowhards, whose rhetoric primes them to either see these critical developments in conspiratorial terms or to indulge in amateurish debunking of complicated research.

Debunk? I’m not trying to do that. I accept the reality of every potential benefit, without relevant caveats. If nothing else, it’s because I don’t need them. It’s all in the truth that not everyone’s cost-benefit analysis will reach the same conclusion. Parents aren’t psychic for what their sons will want.

But I can read the policy statement abstract, the technical report, and its sources to understand where they don’t quite mesh. They don’t support the sweeping, conclusive statements the AAP makes that Bering endorses.

So here’s one of those rhetorical devices that intactivists should appreciate: Cut it out. For every amazing prepuce you save, you’re adding an element of risk and uncertainty for the person attached to it. Nobody can possibly know what viral foes a man will come up against in his life, and if one of them is HIV, your crusade, admirable though you feel it is, may be costing some other parent their child’s life.

Every circumcision adds an element of risk and uncertainty for the person attached to the foreskin. Nobody can possibly know what viral foes a man will come up against in his life, including his parents. If one of them is HIV, he should be wearing a condom. (And maybe consent to voluntary circumcision as an adult, if he’s inclined.) If he becomes infected, the responsibility rests with him, not me. Not that HIV is automatically fatal anymore. It’s also worth considering the possibility that other solutions may be discovered in the future, and maybe before a child born today becomes sexually active.

The framing of costing a parent their child’s life is bizarre, as if parents own their children. Permitting (and encouraging) non-therapeutic male child circumcision treats parents as the owners of their son’s prepuce, which is odd from a human rights perspective, but also from the reality that parents are legally prohibited from acting as if they own their daughter’s prepuce.

AAP Circumcision Policy – Flawed Ethics

Much has already been said on the flaws in the AAP’s revised policy statement on non-therapeutic male child circumcision. (Here’s an additional plug for the exceptional rebuttal by Brian D. Earp.) I want to comment directly on its recommendations and the ethical issues addressed – or unaddressed – in the technical report. First, from page 757:

The Task Force made the following recommendations:

  • Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it.
  • …
  • Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.

These two statements conflict. Stating that the benefits outweigh the risks is a judgment call based on subjective valuations of the various inputs. The task force recognizes this when acknowledging that some parents would value other considerations more than the AAP’s evaluation of the net effect. That same possible difference of opinion applies to the cost-benefit analysis itself, which should include actual costs (i.e. the foreskin) rather than just risks.

The AAP is stating that it’s possible to disagree with the task force, but only to an extent because it reviewed the data and drew a conclusion. That’s wrong because the evaluation requires subjective weightings rather than objective criteria. It’s one thing to question the possible benefits altogether, as some do. It’s also possible to accept the potential benefits while not valuing them more than the costs involved. All individual tastes and preferences are unique. AAP Circumcision Task Force member Dr. Douglas Diekema said as much prior to the release of the revised policy statement. Why is that not reflected here in place of this incorrect statement that the benefits definitively outweigh the risks (and the unmentioned costs/harms)?

Further discrediting its recommendation on this, the ethics section (Pg. 759) states:

… 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 highlighted statement is the ethical argument. This accurate statement contradicts the conclusion the AAP presents that the potential benefits definitively outweigh the risks it considered. It is more relevant in the context of what the individual being circumcised might value. How will he – rather than his parents – want the benefits, risks, and costs weighed against each other for his normal, healthy foreskin? That’s the ethical core that the AAP Task Force sidestepped. Its recommendation for proxy consent for non-therapeutic circumcision is indefensible.

Moving on to the Ethical Issues section (pp. 758-760):

As a general rule, minors in the United States are not considered competent to provide legally binding consent regarding their health care, and parents or guardians are empowered to make health care decisions on their behalf.9 In most situations, parents are granted wide latitude in terms of the decisions they make on behalf of their children, and the law has respected those decisions except where they are clearly contrary to the best interests of the child or place the child’s health, well-being, or life at significant risk of serious harm.10

Sure. But that doesn’t support non-therapeutic male child circumcision. Proxy consent for permanent, amputative surgery must require something approaching objective need. Legally, we already require this for non-therapeutic genital cutting on female minors, including that which is analogous to or less harmful than a typical male circumcision. The comparison to be made for non-therapeutic male circumcision is whether or not parents are given this same non-therapeutic, cultural latitude in cutting the genitals of their daughters. They are not, which demonstrates that it shouldn’t be about the parents but about the child.

(a) Except as provided in subsection (b), whoever knowingly circumcises, excises, or infibulates the whole or any part of the labia majora or labia minora or clitoris of another person who has not attained the age of 18 years …

Subsection (b) establishes that only therapeutic genital cutting is legal for female minors. Subsection (c) rejects all parental preferences, whether cultural or religious, for non-therapeutic genital cutting on their daughters. It’s improper for the AAP Task Force to treat non-therapeutic male child circumcision as if it’s just a health care decision. It’s unlike any other decision we allow. If nothing else, circumcision guarantees (i.e. “significant risk”) the child’s normal, healthy foreskin will be removed forever (i.e. “serious harm”). Do male minors ever become reasonable people who may disagree about the weighting of the benefits and risks?

Revisiting “reasonable people may disagree”:

Parents and physicians each have an ethical duty to the child to attempt to secure the child’s best interest and well-being.11 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. This situation is further complicated by the fact that there are social, cultural, religious, and familial benefits and harms to be considered as well.12 It is reasonable to take these nonmedical benefits and harms for an individual into consideration when making a decision about circumcision.13

It is not reasonable. The individual who must live with the permanent consequences of the decision, if the decision is to circumcise, is not the person taking these non-medical benefits and harms into consideration. (Here, based on my earlier excerpt from this paragraph, benefits such as a reduced risk of heterosexually-acquired HIV should be evaluated as non-medical because they are a non-therapeutic justification for surgical intervention via proxy consent. Or remedy my rebuttal to “these medical benefits, non-medical benefits, and harms” if my precision focused on the lack of need irritates.)

In footnote 13, which is Diekema’s “ethics” perspective on Boldt v. Boldt, he concludes:

(3) Absent a significant medical indication, circumcision should not be performed on older children and adolescents in the face of dissent or less than enthusiastic assent.

This is important. Infants can’t consent, of course, but there is no reason that an inability to consent should be construed as a “yes” in favor of his parents’ preferences. Not even benefits that reasonable people may determine do not outweigh the risks (and costs). From the Ethical Issues section of the policy statement technical report:

Parents may wish to consider whether the benefits of the procedure can be attained in equal measure if the procedure is delayed until the child is of sufficient age to provide his own informed consent. These interests include the medical benefits; the cultural and religious implications of being circumcised; and the fact that the procedure has the least surgical risk and the greatest accumulated health benefits if performed during the newborn period. Newborn males who are not circumcised at birth are much less likely to elect circumcision in adolescence or early adulthood. Parents who are considering deferring circumcision should be explicitly informed that circumcision performed later in life has increased risks and costs. Furthermore, deferral of the procedure also requires longer healing time than if performed during the newborn period and requires sexual abstinence during healing. Those who are already sexually active by the time they have the procedure lose some opportunities for the protective benefit against sexually transmitted infection (STI) acquisition, including HIV; moreover, there is the risk of acquiring an STI if the individual is sexually active during the healing process. (See the section entitled Sexually Transmitted Diseases, Including HIV.)

First, note that it references a section on STDs, including HIV. Condoms are a cheaper, ethical way of achieving the same benefits and in greater than equal measure. They’re also still necessary after circumcision to prevent STDs, including heterosexually-acquired HIV. Yet, the word condom appears¹ zero times in the body of the technical report. Why?

The same applies to the other benefits, or there are safe, effective, non-invasive treatments available. It’s also reasonable to infer that, since people may disagree based on their preferences for whether the benefits outweigh the risks, people may also differ on whether the cited gains from infant circumcision rather than voluntary, adult circumcision are worth the trade-offs of their foreskin and their choice. The “greatest accumulated health benefits” isn’t enough to justify circumcising the individual who will not want to be circumcised.

The most crucial sentence in that excerpt is the third. Males left with their normal genitals are less likely to elect (or need) circumcision. This is too often portrayed as something akin to weakness or cowardice in the autonomous male, for which parents can be the brave, responsible decision-maker. (e.g. Brian Morris et al.) That’s a bad framing device. Instead, this unwillingness (i.e. less likely) is the most powerful indicator that males left with their foreskin value something more than being circumcised. Even if that is merely a desire to avoid the (perceived) pain of the surgery, it is proof of their preference against being circumcised. It is not better to guarantee that pain by forcing it on them in infancy. The typical defense is that they won’t remember it, which is so ridiculous that it could justify any intervention. As AAP Task Force member and bioethicist Douglas Diekema said, “Not everyone would trade that foreskin for that medical benefit.” If the AAP had reflected that view in its recommendations, the revised policy statement could’ve been ethical.

For the remaining sentences, parents who are considering deferring circumcision should be explicitly informed that circumcision performed later in life has a very low likelihood of being necessary. Why leave this point out to focus only on one side of the equation if parents should be fully informed? It shouldn’t be included as an abused throwaway in a technical report most parents will never know exists.

In cases such as the decision to perform a circumcision in the newborn period (where there is reasonable disagreement about the balance between medical benefits and harms, where there are nonmedical benefits and harms that can result from a decision on whether to perform the procedure, and where the procedure is not essential to the child’s immediate well-being), the parents should determine what is in the best interest of the child. In the pluralistic society of the United States, where parents are afforded wide authority for determining what constitutes appropriate child-rearing and child welfare, it is legitimate for the parents to take into account their own cultural, religious, and ethnic traditions, in addition to medical factors, when making this choice.11

It is not legitimate. The Task Force’s own words demonstrate that it’s possible for the individual male to not value circumcision. He is in his parents’ care for 18 years. (Per Diekema’s recommendation, his parents may be able to choose non-therapeutic circumcision for only a few of those years.) He will then be an autonomous adult for what will likely be another 40 to 80 years. What will he believe is in his best interest about his normal body for that time period? If his parents circumcise him, he will never be autonomous on this question. (As his sister(s) will be by law, contra the absurd idea that parents should be afforded wide authority to determine what constitutes his best interest forever.)

This decision involves informed proxy consent, not informed consent. For this, non-therapeutic circumcision, there is no reasonable disagreement about the lack of need. What is in the child’s best interest is to not undergo unnecessary surgery for reasons he may not value. He can choose it later, or his parents can choose it should genuine medical need arise while he remains their responsibility. He can’t unchoose it once it’s imposed.

The technical report does not support the AAP’s recommendations because it contains omissions and contradictions. Both the technical report and the condensed versions are irresponsible documentd that will perpetuate the violation of the bodies and rights of newborn males. They should be retracted.

¹ It appears once in a footnote as part of the title of a source.

Revised Chart – AAP and Declining Circumcision Rates

In the AAP’s technical report supporting its revised policy statement on non-therapeutic male child circumcision, there is a graph depicting the recent trend in circumcision rates, as shown in three studies. The graph is on page 759. Here it is:

As Hugh notes¹ in his annotated version (pdf):

This chart suppresses 100%, making a near 50:50 split look like a large majority.

I edited the original graph to add the missing 30%. (I copied the the bars covering thirty percent and added them above the seventy percent marker.) It provides a different perspective on the current rate.

The difference isn’t huge, and is hardly the most compelling point against the AAP statement. (Neither is the missing 71-100% above.) But it’s difficult to accept that the space saved by stopping at 70% is an acceptable trade-off for the flawed perspective the original chart could create.

¹ As he also points out, the chart begins in 1999. This is not necessarily an egregious decision because they’re relying on studies that look at that time period. Data for the years and decades prior to this is available (pdf), of course, and shows a larger decline in the newborn circumcision rate over the last few decades.

The New Marketing in Action

Last month I showed that the marketing for circumcision had changed again to eliminate any remaining concern for either voluntary or adult. Voluntary, adult male circumcision had been rebranded down to “safe male circumcision”. Here is the inevitable goal being realized in Botswana. Babies to be circumcised:

As a long term plan to fight the HIV/AIDS spread the Ministry of Health will now introduce a Safe Male Circumcision (SMC) programme targeted at male babies and infants. In the past few years the government has been preaching SMC to males who are in sexually active ages.
…

“Towards the end of this year we want to enrol babies in the SMC programme and parents will be sensitised on the programme and its procedures. We have realised that targeting sexually active aged men and youth is not enough; we should have a long term vision for our strategies; targeting babies will result in the country having less people at risk of being infected with the virus in the next 15 to 20 years,” [Conrad Ntsuape, the National SMC Coordinator in the Ministry of Health] said.

When public health officials say voluntary or adult, they never mean voluntary or adult. They are “targeting” and “enrolling” infant males. It’s propaganda.

Also notice the fallacy that circumcising infants will result in fewer people at risk of being infected with HIV in the next 15 to 20 years. That is inaccurate, and a warning sign that they do not understand what they are doing. Circumcising infants will (allegedly) result in more males with a reduced risk of becoming HIV infected during vaginal intercourse with an HIV-positive female. Each male still retains a risk of infection, and without other (more effective) changes, including consistent condom use, men – and their partners – will still become infected. Spreading this incorrect understanding is an effective way to continue the spread of HIV.

Relevant to this problem with marketing:

Media were singled out as not playing a visible role in relaying the message on SMC. Beauty Gakale, the SMC Regional Coordinator said SMC should be given wide coverage to avoid confusion and misconceptions about it in the public. “Media, especially private media have been less active in relaying the SMC message and it is high time they played a role in this. We are also urging political leaders to play their role by encouraging men to undergo the SMC. ”

Public officials should worry about their own mistakes before demanding that media assist them in pushing propaganda. For example:

Asked why the advantages of the SMC are communicated to the public while the disadvantages are hardly discussed, Dr. [Adrienne] Musiige said SMC is like any other surgery and can be susceptible to infection if not well managed.

That didn’t answer the question.

Progress in The New York Times

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

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

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

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

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

Evaluating the Genital Cutting Analogy

Catarina Dutilh Novaes has an excellent post on the comparison between male and female genital cutting.

 A heated discussion ensued from my post on circumcision last week, which in turn was essentially a plug to a thought-provoking post by Brian D. Earp at the Oxford Practical Ethics blog. The controversial point was whether circumcision is or is not to be compared to female genital cutting.

I’ve learned a lot from the different perspectives presented during the discussion; among other things, I’ve learned the terms ‘genital alteration’ and ‘genital cutting’, which now seem to me to be more adequate than either ‘circumcision’ or ‘genital mutilation’ to formulate the issue in a non-question-begging way (as argued here). And yet, I am now even more convinced that the analogy between male genital alteration and female genital alteration is a legitimate one – which (and let me say this again!) does not mean that there are no crucial differences to be kept in mind. That’s what an analogy is, after all.

I agree with this, and the bulk of the post. I recommend it with only a minor quibble and an additional piece of modern evidence.

My quibble:

It is well known that female genital cutting is practiced with different levels of severity, going from pricking and piercing to infibulation. …

I do not believe this is well known beyond academic knowledge. In my experience the average person hearing this comparison believes that female genital cutting is always a) the most severe form, b) performed to eliminate all sexual pleasure, and c) imposed at the insistence of males. Facts rarely correct that misunderstanding when presented. Most often the avoidance rests on imagined parental intent, as if that alone can dictate the outcome.

Modern evidence:

– Female genital cutting is embedded in a long history of oppression of female sexuality, and has as its main goal to diminish women’s sexual enjoyment. Male genital cutting in the form of circumcision has no such goal.

She is citing an objection from the comments of her original post rather than her opinion. She supports the challenge to the claim with the 19th century history of male circumcision in America. That is relevant, but there’s modern evidence that circumcision seeks to control male sexuality. Last year Rabbi Mark Glickman wrote (my post):

… Unlike female genital mutilation, Jewish circumcision is not a way to limit or control the child, and it does not destroy sexual desire.

Many find the practice troubling, I believe, because it so dramatically distinguishes religious values from commonly accepted modern American ones. America idealizes nature; Judaism and other religions try to control it and improve it. …

There are other examples. Religion still seeks to control the child and his sexuality through circumcision. A lack of ill intent does not negate the control from circumcision or its intentionality.

In a cultural rather than ritual context, circumcision is still about control. Parents circumcise so the boy will “look like his father”, regardless of what the child wants. Parents circumcise so that his sexual partners will not be repulsed. (This is an indirect form of control of his future sexual partners.) Parents circumcise to avoid STDs, even though condoms are still necessary. All of this controls the child and his sexuality. The control of males through non-therapeutic genital cutting is rarely as extreme as it is for females, but it is real and occurs now. There is no need to rely on history. The analogy holds up here.

Flawed Circumcision Defense: Rabbi Shmuley Boteach

Rabbi Shmuley Boteach has an opinion piece in The Wall Street Journal titled, “Germany’s Circumcision Police”. It starts off well.

There was a head-spinning moment in Germany last week: News emerged that a rabbi had been criminally charged for performing his religious duties. Rabbi David Goldberg of northern Bavaria, who shepherds a 400-member community, is the first person to run afoul of a ruling by a Cologne judge earlier this year that criminalized circumcision, a basic religious rite.

There is some precedent outside of Germany for such a ruling. …

Even though we disagree on policy, agreeing on basic facts is always good. But his essay slowly falls off the path.

… In the United States, a San Francisco ballot initiative tried last year to make circumcision an offense punishable by a $1,000 fine and up to a year in prison; it failed to get enough votes. …

That’s not an accurate summary of what happened last year. A court ruled that the local ballot initiative conflicted with an existing state law and struck it from the ballot. It had nothing to do with getting enough votes.

… But the circumcision ban deserves universal scorn.
…

Does the German government really want to get into a public battle over whether they are better guardians of the health and welfare of Jewish (and Muslim) children than their parents?

As long as parents continue to circumcise their healthy sons, I hope so. Obvious physical harm for subjective non-therapeutic benefits is unacceptable without the individual’s consent. Protecting the rights of all citizens is a legitimate role of the state.

The Los Angeles Times recently cited a study predicting that as the number of circumcisions goes down in the U.S., the cost of health care will steadily climb. Eryn Brown reported that “If circumcision rates were to fall to 10% . . . lifetime health costs for all the babies born in a year would go up by $505 million. That works out to $313 in added costs for every circumcision that doesn’t happen.”

I’m not impressed by Rabbit Boteach endorsing the idea that a child’s normal body – and by extension, his rights – has a price beyond which we’ll justify non-therapeutic intervention to remove parts of it. But, more importantly, the key in that is not $313. It’s predicting. Aaron Tobian and his co-authors used a data model to make a guess. There are many factors involved. They are not constant. Cost, availability, and need could be quite different in two decades. For the potential benefits against sexually transmitted infections, circumcision can be chosen later. That would match the ethics of the studies that used adult volunteers. This study seeks to “prove” that a specific, non-urgent solution should be applied now, regardless of ethics.

Why? Because circumcision has been proven to be the second most effective means—after a condom—for stopping the transmission of HIV-AIDS, with the British Medical Journal reporting that circumcised men are eight times less likely to contract the infection.

He gets credit for mentioning condoms, which puts him ahead of the AAP. Still, condoms provide greater protection than circumcision, and remain necessary after circumcision. So, cost-wise, it’s condoms or condoms and circumcision. The former is cheaper and ethical. Infant circumcision is not ethical, including when potential benefits against STDs are cited.

While the Germans decry the barbarity of circumcision for men, they also overlook the benefit to women who are the men’s partners. Male circumcision reduces the risk of cervical cancer—caused by the human papillomavirus, which thrives under and on the foreskin—by at least 20%, according to an April 2002 article in the British Medical Journal.

They overlook the potential benefit to women? Do they? They can agree that (voluntary, adult) circumcision may confer reduced risk to female partners while also finding it unacceptable to impose circumcision on infant males (i.e. not “men”). Rabbi Boteach ignores the ethical foundation for the court’s ruling.

While some attempt to equate male circumcision with female clitoridectomy, the comparison is absurd. Female circumcision involves removing a woman’s ability to have pleasure during sexual relations. …

Not necessarily. Yet, in spite of that, it remains unethical. At some point, the human rights principle(s) involved must factor. Equal protection is a human rights principle.

… It is a barbarous act of mutilation that has no corollary to its male counterpart. …

This is also not true. Within what he wrote, it is, because he limited himself to clitoridectomy. The scope of illegal female genital cutting/mutilation is much broader than that, including any cutting that is anatomically analogous to (or less harmful than) male circumcision. That’s relevant.

… Judaism has always celebrated the sexual bond between husband and wife. Attempts to malign circumcision as a method of denying a man’s sexual pleasure are ignorant. …

Male circumcision controls male sexuality, with a long history as an attempt to limit sexual pleasure. It is still used to reduce pleasure for males.

… Judaism insists that sex be accompanied by exhilaration and enjoyment as a bonding experience that leads to sustained emotional connection.

If we ignore explicit statements in favor of circumcision as a way to diminish male sexual pleasure, Rabbi Boteach’s claim here is not mutually exclusive from reduced sexual pleasure. Intent does not guarantee outcome.

We Jews must be doing something right in the bedroom given the fact that, alone among the ancient peoples of the world, we are still here, despite countless attempts to make us a historical footnote.

This is evidence that male circumcision does not eliminate male reproductive ability. No one has claimed it does. His statement is a non-sequitor. The ability to reproduce is not proof that circumcision is acceptable or that it does not affect sexual pleasure or inflict harm.

Related: From the Cut Podcast, a debate between Rabbi Shmuley Boteach and Cut director Eliyahu Ungar-Sargon.

AAP Task Force Member Douglas Diekama Maligns Circumcision Opponents

The Washington Post’s parenting blog has a new post, ‘Intactivists’ furious at new AAP circumcision policy, that contains a misdirection from Dr. Douglas Diekema. After quoting Ronald Goldman and a few commenters to an earlier post, this:

AAP officials expected such a reaction.

“For individuals who have decided that circumcision is wrong, no amount or quality of data will put these questions to rest,” Douglas Diekema, who served on the AAP task force that wrote the report, told me last week when I asked him about potential pushback.

Diekema implies that people who are against circumcision simply haven’t correctly considered the data, which means “reached his personal conclusion”. He implies that opponents have made a demonstrable error in judgment. This is nonsense. It’s consistent to accept every single piece of data the AAP considered, and to ignore the relevant information the AAP explicitly ignored in its consideration, yet reach the conclusion that non-therapeutic infant circumcision is unjustified medically (and ethically), contra the AAP’s biased and flawed statement. To quote Douglas Diekema himself:

… But it does have medical benefit. Not everyone would trade that foreskin for that medical benefit. …

No kidding. That’s the ethical issue, but it also shows that the benefits do not outweigh the risks for every individual. Diekema is engaging in propaganda, facilitated by The Washington Post. Both aspects of that are inexcusable.

I’ve sent an e-mail to the Washington Post blogger, Janice D’Arcy, asking for comment on Diekema’s problematic quote. I will update if I receive a response.

Brian D. Earp on the AAP’s Flawed Circumcision Policy Statement

If you read only one analysis on the AAP’s revised policy statement on infant circumcision, make it this fantastic deconstruction by Brian D. Earp. It’s almost too perfect to excerpt. This is a great sample, but his entire post is required reading.

Here they depart from their 1999 statement in asserting that (1) the benefits of the surgery definitively outweigh the risks and costs and (2) that it is therefore justifiable to perform the operation without the informed consent of the patient. This does not follow. In medical ethics, the risk/benefit rule was devised for therapeutic procedures aimed at treating an extant pathological condition, and for minor prophylactic interventions such as vaccination. It has no relevance to nonessential amputative surgery, especially when it involves the painful removal of healthy, functional erogenous tissue from the genitals, and when safer, more effective substitute strategies exist for achieving the same ends.

You may be surprised to learn that the word “condom” does not appear even once in the 28 page AAP report.

In making their risk/benefit calculations, then, the AAP simply leaves out a critical bulk of factors relevant to the equation, including the existence of a range of proven healthcare tools like condoms, vaccines (including an effective HPV vaccine), and antibiotics. If they had bothered to consider human rights and bodily integrity issues, the function of the foreskin, its value to the individual, and his possible wishes in later life, as well, their computations would quite plainly yield a very different answer.

Seriously, it’s worth the time. And share it far and wide.