Author: Tony

Flawed Circumcision Defense: Dr. Ruth Westheimer

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Anti-Science and the Lack of Need for Circumcision

To put the alleged anti-science position of those who oppose non-therapeutic child circumcision into perspective, consider what the most determined proponent of routine circumcision, Brian Morris, has to say on the foreskin’s risks (From his brochure¹ “Circumcision: A guide for parents”):

… 1 in 3 uncircumcised boys will, as a result of having a foreskin, develop at least one condition requiring medical attention. …

Another way of saying that is that 2 in 3 boys will not, as a result of having their foreskin, develop at least one condition requiring medical attention. A male will more likely than not maintain his genital health throughout his life and retain the benefits of having a foreskin. That is also science. That’s important to remember in the midst of the fear promoted to encourage circumcision.

Morris also provides an inference in that statement detrimental to his argument for non-therapeutic circumcision. He is stating that 1 in 3 intact boys will require medical attention for a foreskin-related malady. He is not stating that 1 in 3 intact boys will require circumcision. As I pointed out in my last post, the ability to treat maladies is also science. If that medical attention is for a UTI, the male can take antibiotics. If that medical attention is for (genuine²) phimosis, he can use topical steroids and skin stretching techniques. And so on. Morris provides no information in this claim about the actual risk of medically-necessary circumcision within an intact male’s lifetime. All we know is that it’s something less than 1 in 3 intact males. Yet he proceeds in all of his work with the primary assumption that all infant males should be circumcised because less than 1 in 3 will require medically-necessary circumcision.

The proper focus should be on how to keep males healthy, not how to wound their genitals upon birth. Science is the key embedded within our position against non-therapeutic child circumcision. We accept science. We know it works for all people and wish to apply it throughout a male’s life. His healthy foreskin and bodily autonomy do not need to be sacrificed to fear.

¹ I don’t provide hyperlinks to propaganda. The brochure is at: http://www.circinfo.net/pdfs/GFParents-EN%28AU%292012.pdf

² To understand the fallacy of Morris’ position, consider this warning from the Medical Journal of Australia:

A high rate of unnecessary circumcision surgery for phimosis – a pathological condition where the foreskin cannot be retracted – has been detected in boys aged under five, despite the rarity of the condition in children of this age, and a marked overall fall in the rate of circumcision in Australia.
…

The team adds that if the 1999 rate remains stable, about 4 per cent of all boys will be circumcised for phimosis by the time they reach 15 – a rate seven times higher than the estimated occurrence of pathological phimosis.

Remember that Morris (and Jake Waskett, Aaron Tobian, Ronald Gray, Robert Bailey, Daniel Halperin, and Thomas Wiswell, among others) published as fact a claim that “all boys are born with phimosis”. To be fair, their paper is newer, but they do not provide evidence to support the claim. An explanation for why they do not may be inferred.

Circumcision: A Limited View of Science

I posted the following on Twitter today:

It’s bizarre how insistent many circumcision advocates are that science only exists on the blade of a scalpel. Science is so much more.

I think this is a decent summation of the accusation many circumcision advocates make to discredit the fight for equal genital integrity and bodily autonomy. They claim, whether or not they believe it, that disapproving of non-therapeutic circumcision on children somehow signals a rejection of science. That’s nonsense, bordering on ad hominem. It’s the same thread of empty rhetoric that created a brief spurt of “so you want Africans to die of HIV?” when researchers released the first HIV trial results.

The problem is obvious. Rejecting the non-therapeutic circumcision of children is not a rejection of science. In critical ways, it’s an embrace of science and its power lacking within circumcision advocacy. It’s a recognition that science is so much more than what happens from the blade of a scalpel. It’s an acknowledgement that we are not so primitive that we must fear risks that circumcision aims to reduce. The diseases are not shrouded in mystery warranting immediate, radical intervention on healthy children.

By definition non-therapeutic (i.e. prophylactic) child circumcision occurs on a healthy child. His health is scientific. This must not be omitted from the discussion. No genital surgery is indicated, just like no heart surgery, brain surgery, or any other surgery is indicated or justified. We don’t call those who reject other interventions that may achieve some potential benefit anti-science because good health as science is an obvious concept. It wraps with ethics, and we have no agenda elsewhere. The same can once again be true of the foreskin within society as a whole.

It’s also useful to remind those who accuse opponents of non-therapeutic child circumcision of being anti-science that science developed preventions and treatments for the diseases and infections that prophylactic circumcision targets. Antibiotics are science. The HPV vaccine is science. Condoms are science. The list of options available before resorting to circumcision is vast. We advocate for science and the ability scientific progress grants us to apply conservative, non-invasive interventions to prevent or resolve medical problems. The charge that we are anti-science because we do not advocate for the most extreme intervention possible is ludicrous.

Two simple questions are the most powerful rebuttal we have. Why is the science supposedly encouraging circumcision – the subset of science convenient to that position – the only science on which we’re supposed to focus? Why should we ignore most of the tools the human mind has uncovered that allow all of us, including intact males, the opportunity to live healthy lives? Considering the full realm of science promotes the proper ethical application of science that protects the rights of individuals as human beings with full bodily autonomy. Advocating for non-therapeutic circumcision on non-consenting individuals is the weaker scientific position.

Avoiding Circumcision Regret

Addressing parents who circumcised or intend to circumcise despite the compelling evidence against the practice remains our biggest challenge as activists for genital integrity and bodily autonomy for all. Since cultural change is the most likely (and probably most effective) route to ending non-therapeutic child circumcision, we have to confront it. Logic matters, which is my preferred route. But emotion matters, too. Kindness and decency can contribute to the discussion and sway parents into protecting their sons the way they would protect their daughters if someone suggested genital surgery on them.

In that approach, I think this post at Mothering achieves a brilliant mix of logic and emotion. A mother wrote it to her son before the circumcision, which never occurred because her son benefited from her persistence in wanting to do the right thing for him. (It also helped that the urologist selected for the possible circumcision embraced ethics¹ enough to be uncomfortable without consent from both parents.) Thus, the letter she wrote to her son to apologize for allowing him to be circumcised instead became an excellent testament to the arguments against circumcision. I strive to achieve this power in my writing.

Dear XXXX,

You’re cuddled up peacefully against me. You’re so happy and innocent and perfect. You’re four days old and you are amazing. I want to give you everything. And I’m already failing you. I’m so sorry, XXXX. I won’t ask you to forgive me because I’ll never forgive myself. I’m your mother and it’s my job to protect you. And I don’t know how to do it. This week, your dad and I will take you to a doctor’s office. They will strap you to a board and cut off a perfectly healthy part of your body. The most sensitive part of your perfect little body will be raw and sore. There is no medical reason for us to do this to you or put you through this pain. But we’re doing it anyway. I don’t know how to stop it. I am failing you. Letting this happen goes against everything I ever wanted to teach you. I don’t know how I’ll be able to look you in the eyes after I do this to you. How can I teach you to love your body when I’m showing you that your body wasn’t good enough? How can I teach you to be confident in being who you are when we’re putting you through surgery just so you’ll fit in? How can I teach you to love and accept others the way they are when we’re rejecting your perfect little brand new body the way it is? How can I teach you to believe in yourself and believe that you can do anything if we think your body needs surgery because we don’t think you’re capable of basic hygiene? And how can I teach you that God made you when I’m showing you that God made a mistake? I’m so sorry for not protecting you. I’m so sorry that I will never be able to be the mother that you deserve now. Please know that I believed in you, XXXX. I believed that you would be a strong, confident man who would love his body the way God made it, love who he was, and not give a damn about what other people thought you should look like or who you should be. I fought for you, XXXX. I just didn’t fight hard enough, and I will regret that for the rest of my life. And I will spend the rest of my life trying my best to undo the damage that I’m letting be done. I will always cherish these first few days of your life, when you were still whole and trusting and the happiest baby I’ve ever seen. The days before I failed you. I love you, XXXX. I’m so so sorry.

Love,
Mommy

This follow-up provides a nice perspective from the mother after she kept her son safe.

Via @IntactVoices.

¹ If only that urologist understood the ethics of circumcising without consent from the healthy patient…

More on the Fallacy of VMMC: Infant Volunteers

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

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

Providing VMMC Services

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

Costing and Impact Summary

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

The key policy topics addressed by the model are:

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

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

  • …

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

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

Medical Male Circumcision

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

  • …

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

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

4.2.2 Voluntary medical male circumcision (VMMC)

Evidence

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

Program Implementation

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

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

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

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

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

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

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

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

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

**********

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

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

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

Politics: Legitimate and Illegitimate Medicine

I strive to avoid political topics here that stray beyond direct, immediate applicability to genital cutting. We all have our own set of beliefs. I have mine, but I do not wish to turn anyone away from Choose Intact’s focus because we disagree on something unrelated. I write this with that idea in mind, although I don’t think the comparison I’m about to make is particularly controversial.

The challenge we face as advocates for bodily integrity and autonomy for all revolve around the two core facts in what we oppose: non-therapeutic genital cutting on non-consenting individuals. This story (from 11 days ago) involves a comparison on both points (emphasis added):

A District Administrative law judge Monday refused a request from a Wisconsin Avenue pain doctor to reverse temporarily a decision by the DC Department of Health that stops him from writing prescriptions for powerful pain medications.

Dr. Alen Salerian runs the Salerian Center for Neuroscience & Pain in far Northwest, and had his right to prescribe Class Two narcotics suspended earlier this month. That action followed by less than two days, and contradicts, a Drug Enforcement Administration decision that allows him to write these prescriptions until 2015.

In court documents, The Department of Health maintains Salerian “has prescribed highly addictive controlled substances to patients without medical sufficient necessity.”

With pain management, the government prohibits a doctor-patient relationship where a therapeutic need exists and all parties consent in order to achieve some tangential (i.e. irrelevant) political objective. That is, our government holds the belief that “Drugs are bad” higher than the care and well-being of individual citizens. It rejects science because it’s not politically acceptable. Real people are suffering because we’re allowing politics to prohibit medicine.

With genital cutting, the government creates a doctor-patient relationship where no therapeutic need exists and not all parties consent in order to order to achieve some tangential (i.e. irrelevant) political objective. That is, our government holds the belief that “Parents may choose (for their sons only)” higher than the care and well-being of individual citizens. It rejects science because it’s not politically acceptable. Real people are suffering because we’re allowing politics to encourage culture masquerading as medicine.

As I said, I have an opinion on the story beyond the scope of this blog. If yours differs, I think and hope we can disagree without disputing the hypocrisy this post highlights. Here we have a scenario for activists that demonstrates exactly why the individual needs to be the primary concern in our activism for genital integrity. Anything that disrupts the focus from individual people – the distinction between patient and victim – is our target. We need to continue interacting with our elected representatives to eliminate this hypocrisy and to correct our approach to rights, ethics, and science. It’s currently skewed away from all three. If our representatives won’t listen, we can and should work to elect new, better representatives.

Link via The Agitator.

Flawed Circumcision Defense: Mitchell Warren

Mitchell Warren, the Executive Director of AVAC, penned an essay at the Huffington Post titled The “Best Hope” for AIDS Vaccine Advocacy. If it was just that, it would be fine. It’s not just that because it never is, although it takes digging beyond the article itself to find the problem.

He begins this essay about searching for an HIV AIDS vaccine:

There is growing global momentum behind the call to begin to end the AIDS epidemic using the scientifically-proven options available today. These include voluntary medical male circumcision, antiretroviral therapy (ART) — which dramatically reduces risk of HIV transmission between stable sexual partners — and prevention of pediatric infection during pregnancy, delivery and breastfeeding. If taken to scale with resources and urgency, these core components of combination prevention, along with other key prevention interventions, can save lives, prevent new infections and lower the price tag for the global AIDS response over the long term.

Well, sure, if we’re talking voluntary medical [sic] male circumcision, there isn’t an immediate problem. Such a strategy works to re-enforce and extend infant male circumcision in the long-term, and that needs to be addressed. But, by itself, voluntary medical¹ non-therapeutic male circumcision is a choice an individual may make for himself.

That’s never where it ends. AVAC describes itself (emphasis added):

Founded in 1995, AVAC is a non-profit organization that uses education, policy analysis, advocacy and a network of global collaborations to accelerate the ethical development and global delivery of AIDS vaccines, male circumcision, microbicides, PrEP and other emerging HIV prevention options as part of a comprehensive response to the pandemic.

Its focus on ethics is so robust that it randomly drops voluntary from “voluntary medical male circumcision” on its circumcision page. Its focus on ethics is so sincere that AVAC once issued a press release quoting Mr. Warren supporting:

“Research and dialogue are also needed now to explore the feasibility of rolling out infant circumcision. This approach will not show immediate benefits in terms of HIV incidence but can minimize risks and could be a highly cost-effective implementation strategy over the long term.”

To be fair, that press release is more than five years old. But the site also includes a link to a 2010 paper co-written by Brian Morris titled, “The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV”. And the Women’s HIV Prevention Tracking Project (WHiPT), a collaborative initiative of AVAC and the ATHENA Network, released a report (pdf) in December 2010 titled “Making Medical Male Circumcision Work for Women”. Question: why is voluntary missing in voluntary medical male circumcision? The report, as suggested by the missing “Voluntary”, is full of YAY INFANT CIRCUMCISION. For example, on page 9, under Next Steps for WHIPT Advocacy based on the findings:

Over the next year, WHiPT teams will execute advocacy plans based on their findings. Actions include:

  • …
  • Investigating the benefits and disadvantages of infant male circumcision

So, AVAC’s notion of ethics includes the ability for one person to “volunteer” another person for non-therapeutic surgery. I’m not surprised. It’s page on ethics includes:

The term ethics addresses ideas of right and wrong and with moral duty and obligation. Research ethics address “rights” and “wrongs” surrounding research that uses human participants to find answers to scientific questions. The primary focus of ethics guidelines for research in humans is safeguarding the rights, dignity, and health of the trial participant.

What about the ethics of applying the findings of research to non-consenting, healthy individuals? That is also a valid question that AVAC is apparently willing to ignore. Or should I read its position to mean these ethically-developed strategies are to be applied globally without further concern for ethics in applying those strategies? My analysis would be irrelevant in that reading. Of course, AVAC would still be very unethical, but my analysis would be wrong. I’m not that cynical, so I don’t read it that way. Onward.

The WHiPT report continues with its recommendations for Kenya (page 15):

The Ministry of Health should consider the integration of MMC for infants into the maternal and child health facilities, given the long-term benefits as well as the safe and inexpensive nature of the procedure.

I’ll ask again: why is the “V” missing in VMMC? Of course it wouldn’t make sense when talking about infant circumcision because that’s not voluntary. But the ethical position is to drop infant circumcision, not voluntary. The latter is just a matter of convenience in pursuit of an improperly-stated goal. (An improperly-stated goal could also be called “lying”.)

In its Uganda findings (page 55):

Almost one-third of the respondents said they would circumcise their infant boys if MMC were protective against HIV (33.3 percent for Kampala and 27.8 percent for Kapchorwa).

From its conclusion and recommendations for Uganda (page 57):

From the documentation, it is clear that women are aware of traditional/religious male circumcision but have little knowledge of MMC and its benefits to them. On the same note, women are not empowered in decisionmaking around MMC—with either their spouses or their infants. Policy makers should consider the social and gender implications of MMC in the community, if it is to be appreciated and beneficial to both men and women.

MMC acceptability and use in communities revolves around promotion, advocacy and sensitization efforts undertaken by the government, implementers and advocates.

  • Government and advocates must provide increased sensitization of women, with enough clear information about MMC before the community is prepared for its uptake.
  • Government, advocates and community leaders need to address the myths and bring facts about MMC with evidence-based information to communities.
  • Government and implementers must develop an MMC package that will integrate sexual and reproductive health with gender equity and empower women to get involved in decision-making, especially on condom use.
  • Implementers must impart knowledge and skills in decision-making regarding the circumcision of their male infants.

The “V” is missing everywhere. I’m starting to think the “V” key must be broken on every keyboard AVAC to which AVAC has access. That, or they only care about circumcision without regard to the ethics of voluntary action.

For further demonstration of the point, from the findings and recommendations surrounding the conflation of voluntary medical male circumcision and female genital mutilation, the report states (page 8):

• Advocates must monitor efforts to clarify the distinction between MMC and FGM.

There are distinctions in degree, which is what the researchers intend as proof that the difference is in kind. They are wrong, but temporarily, let’s accept their mistake as valid. Even with that requirement, there is one distinction between MMC and FGM that can’t be made, despite the group’s expectation that this distinction is obvious. Neither MMC nor FGM is voluntary. Both are forced on the recipient (i.e. victim) by another person. If the recommendation focused on the difference between VMMC and FGM, then the distinction would blink in neon. But they can’t include that because the entire premise of infant circumcision requires a complete rejection of the ethics of voluntary without regard for the defensibility of that rejection.

Basically, it’s clear that AVAC cares about the ethics of circumcision only as far as it’s useful in pushing circumcision. Where ethics permit circumcision, the concept matters. Where ethics reject circumcision, just drop the “V”. Circumcision is an AVAC objective, not ethical circumcision.

¹ I strike medical because the term advocates are looking for is medicalized, or something implying a sterile facility with modern surgical tools. I assume medical is also meant to convey the pursuit of potential benefits, but that too conveniently omits the ethical aspect of non-therapeutic circumcision. Thus, I have no interest in promoting loose wording.

Economic Principles Applied to Circumcision

I’m a huge fan of economics because it provides useful, widely-applicable lessons. Economist David Henderson created a list of The Ten Pillars of Economic Wisdom that is quite useful. Several of the principles apply directly to the issue of genital integrity. The principles obviously connected to the basic human right of genital integrity, from the current version (originally published in The Joy of Freedom: An Economist’s Odyssey):

1. TANSTAAFL: There ain’t no such thing as a free lunch.

Circumcision is commonly sold in the U.S. with a long list of benefits and a tiny list of supposedly rare risks. The challenge is that the former is only potential and the latter is incomplete. There is no such thing as a free lunch. Circumcision is more than a bunch of benefits in exchange for “a useless flap of skin”. In addition to the inherent risks of surgery, circumcision has permanent costs that last long beyond the surgery itself. This is what’s ignored. Most advocates of non-therapeutic child circumcision omit this. (Brian Morris is probably the most egregious offender on this point.) They treat the surgery as a free lunch. “Look at the potential benefits” they say. Even this, which is better than most lists, omits the full range of costs. There is no discussion of the mechanical change. There is no discussion of the foreskin as a normal anatomical structure or what’s lost. It’s just ignored, as if it’s not a cost. This omission is incorrect. (This is related to another economic principle.)

2. Incentives matter; incentives affect behavior.

The most obvious example is the third-party payment system within the United States that generally pays for non-therapeutic circumcision of children. Parents don’t see the full financial cost because it’s spread out among the full range of insured Americans. It’s as if it’s a free lunch because the direct cost is hidden.

This is also seen with Medicaid. Where it’s not funded by the state, fewer low-income parents impose non-therapeutic circumcision on their sons. (I reject the nonsense offered by advocates like Dr. Edgar Schoen¹ and Colorado State Senator Joyce Foster – for reasons related to several of these economic principles – when they say Medicaid funding is a matter of social justice.)

As an aside, I do not accept the argument that a single-payer government insurance system in America would automatically result in the near-extinction of non-therapeutic circumcision in America, as it has in a country like England, by removing the financial incentive. I’ve long voiced a level of skepticism on this for reasons influenced by this economic principle. Incentives matter. The hidden financial cost of circumcision is not the only incentive in America. The idea that circumcision is “patriotic” (to cite Schoen, among several) rests on a non-financial incentive. The fear that family, classmates, and/or future sexual partners will shun an intact male is an incentive. These are cultural and will not disappear if the only change in society is that parents will carry the full financial cost of imposing circumcision on their (male only) children. I’ve encountered too many examples of parents complaining that they “have” to pay for their son’s unnecessary circumcision because their insurance plan won’t cover it to think otherwise.

6. Every action has unintended consequences; you can never do only one thing.

This is related to the no free lunch principle. Parents and medical professionals think that allowing proxy consent on this involves doing what’s best for their son. Parents who circumcise are assumed to achieve this – and only this – outcome. However, the action eliminates the child’s personal choice. That is not generally intended, on the “parents are well-intentioned” fallacy that ignores the act of circumcision. But circumcision is not just reducing risk X or whatever argument parents use. It’s also whatever the child decides about circumcision. Perhaps his opinion will align with his parents’. Perhaps not. Either way, his choice is gone.

Also, the funds and labor used for circumcision are no longer available for therapeutic treatments or other pursuits. This is an unintended consequence.

7. The value of a good or a service is subjective.

This is the key point here. This applies to all circumcisions, but with non-therapeutic circumcision, it’s especially true. There is no objective need, no reason to impose this on someone who can’t consent. The value of the intervention rests with the recipient. Again, perhaps his opinion will align with his parents’, but perhaps not. Society permits (and often encourages) parental proxy consent. The value is placed exclusively on the parents’ subjective valuation of the potential benefits and (often ignored) costs of non-therapeutic circumcision. The child’s possible objection is ignored in favor of his parents’ preferences about his body. In my case, my parents paid for a circumcision that I wouldn’t choose to accept if I were paid an enormous amount of money to undergo the procedure. Their valuation doesn’t match mine for the service.

These principles help make the ethical case. A permanent, non-therapeutic alteration should never be imposed on someone who does not consent.

¹ Dr. Schoen, especially, since he writes “[t]his means that many poor families are unable to choose to receive a circumcision…”. The family doesn’t receive the circumcision. The child does. Dr. Schoen’s position on the ethics of non-therapeutic circumcision is idiotic and untethered from anything other than is subjective valuation. As economic principle number seven shows, the valuation of everyone other than the patient is irrelevant in the imposition of circumcision.

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

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

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

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

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

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

Lawsuits as Strategy

I resisted commenting on this story. I don’t think it’s worth our time as activists for several reasons. One, the petitioner, Dean Cochrun, is an inmate in prison for kidnapping. He’s not exactly a sympathetic individual, even though I agree with the gist of his claim. Two, He’s representing himself. He’s going to make a mess of this, on the off chance it proceeds beyond his initial filing. I read his self-written complaint to judge it. I’m not an attorney so I’m not sufficiently qualified in much of the debate. Still, it’s clear how unfocused and emotional his claim is, when there’s a legitimate approach based on objective facts about circumcision and the unethical disparate treatment of healthy boys and girls. We can do better.

There are some relevant topics to discuss, though, which are brought out in this report by Stephanie Rabiner, Esq. at FindLaw. (Again, the caveat applies that I’m addressing these concerns from a layman’s perspective.)

Can circumcision rob you of your, uh, “sexual prowess”?

A South Dakota man thinks so, which is why he has filed a federal circumcision lawsuit against the hospital where he was born. He claims he only recently learned of his missing foreskin, and that doctors misled his mother into believing the procedure was medically necessary.

This is a fair reading of the complaint, but I don’t think it’s complete to say the he claims doctors misled only his mother. Mr. Cochrun wrote “Unknown Doctor who performed this procedure had misled my mother by failing to inform her that there are no medically necessary reasons for performing this procedure and so by the Unknown Doctors acts or omissions I was permanently and irreversibly scarred and deformed.” In the next two sentences he wrote: “By doing so the Unknown Doctor infringed upon the rights of my mother, father, and self. My mother and father were unable to make an informed decision because they were not provided with the facts necessary.” He references both his parents. This speaks to my claim that his suit is unfocused and poorly structured.

His argument is also problematic because it implies that parents have a right to impose non-therapeutic genital cutting if they’re sufficiently informed. They don’t, partly because they can’t be. The only rights involved in non-therapeutic genital cutting, those that were violated, belong to Mr. Cochrun. That should be the approach for any lawsuit, even if arguing that parents are insufficiently informed of the harms and risks of circumcision is a path to the inevitable, eventual recognition of genital integrity for all children.

Ms. Rabiner’s analysis continues, after a bit of laughing because of his name (an immature aside suggesting she hasn’t quite applied a sufficient openness to the general claims represented within Mr. Cochrun’s suit):

Cochrun, 28, is currently in prison on a kidnapping conviction, according to the Associated Press. This may explain why he had both the time to file such a strange lawsuit and why he only recently became aware that he was lacking in the foreskin department.

Unnerved by this revelation, he now claims he “was robbed of sensitivity during sexual intercourse.” The circumcision lawsuit further states that he lost “the sense of security and well-being I am entitled to in my person.”

Whether or not Mr. Cochrun is truthful in his claim, I do not find it difficult to believe that someone would not know he is circumcised (or intact). It’s common, as demonstrated in studies and anecdotal reports. Culture is weird in many ways. Dismissing such a revelation because it contradicts an assumption suggests we should check the assumption.

But, to the analysis within her post (link in original):

This is all well and good — and a little sad, to be honest — but it’s almost certain that a judge will toss Dean Cochrun’s suit. Here’s why:

  1. Consent. Cochrun was an infant when he was snipped, which means his mother had the legal right to consent to the procedure. There’s no indication that doctors lied to her.
  2. Statute of limitations. Personal injury lawsuits can’t be filed 28 years after the events in question. Sure, some states may toll – or pause – the clock and only restart it when the victim first learns of the injury. But it’s highly unlikely Cochrun didn’t know he was circumcised.
  3. Lack of jurisdiction. Cochrun lives in South Dakota. The hospital he is suing is in South Dakota. He has filed a state law tort claim. He filed his circumcision lawsuit in federal court. Federal courts have no jurisdiction to hear his claim.
As to this third point, even if Dean Cochrun re-filed his circumcision lawsuit in state court, the first two points will still apply. His lawsuit will undoubtedly be cut short.

In reverse order… The last point is the key here, which I didn’t process on my first reading. (Give me an ‘F’ in Civil Procedure, I suppose.) But, yes, that’s the best defense of my request not to get behind this suit or make too much of it. But even if he refiled in a state court, my opinion doesn’t change.

On the second point, from the included link:

… A child or a person with a mental illness is regarded as being incapable of initiating a legal action on her own behalf. Therefore, the time limit will be tolled until some fixed time after the disability has been removed. For example, once a child reaches the age of majority, the counting of time will be resumed. …

If this South Dakota code is what would apply in state court and I read it correctly¹, the clock began on Mr. Cochrun’s 18th birthday and ran out on his 19th birthday. Arguing that this suit is faulty because he filed 28 years after his circumcision seems to be incorrect. It should be that he filed 9 years too late. For purposes here, I’m granting that Mr. Cochrun’s “[m]ere ignorance of the existence of a cause of action” did not toll the statute of limitations because “the facts could have been learned by inquiry or diligence”, even though I’ve already demonstrated that it’s possible he may not have known his circumcision status until recently. Whether or not it’s true, it could be. It deserves serious consideration, even if it doesn’t change the conclusion on Mr. Cochrun’s claim.

Speaking of what deserves serious consideration, the correct consent argument relevant to non-therapeutic child circumcision is not presented in Ms. Rabiner’s analysis. I have no doubt that she’s correct that the consent involved rests on legal rather than right. It’s also probably nuanced and complicated with a long history in the common law. But that’s what needs to change. It already has with respect to female minors, so the notion that parents have a right to surgically alter (i.e. harm) a healthy child, but only a male child, is odd and needs to be relegated to the past as a relic of flawed, inexcusable human thinking. If it’s a right, it’s a right against all healthy children, not just male children. Any continued defense of a discriminatory distinction as a parental right is a problematic continuation of our shallow, uncritical thinking on the harm of circumcision. Non-therapeutic genital cutting on a non-consenting individual is either wrong or it’s not.

The best way to achieve full protection of genital integrity and bodily autonomy is through cultural change. It’ll be the most likely to last. But that’s slow, and real individuals have their rights violated while that change develops. Thus, other methods are valid to achieve the same result. Next best is to have elected officials extend the protection we provide to everyone but male minors to male minors, as well. Given how likely that is(n’t), other options are necessary. Which leaves us with lawsuits. The courts are (hopefully) an impartial place to work out these issues to respect the rights of all individuals. Punishing those who violate the rights (and bodies) of children, even if punishment occurs only in civil court, will circle back as an incentive on cultural change. The idea of Mr. Cochrun’s lawsuit is spot on, even where it’s execution is misguided and flawed.

¹ Any lawyers who may read this, please don’t be afraid to correct me on this.