Category: FCD

The AAP Discounts Its Patients’ Right to Physical Integrity

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

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

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

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

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

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

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

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

The AAP continues its challenge:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Their conclusion:

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

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

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

Dr. Douglas Diekema: Still Inconsistent on Circumcision

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

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

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

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

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

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

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

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

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

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

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.

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.

The AAP Worsens Its Flawed Circumcision Position

A lot has already been said about the AAP’s revised policy statement on non-therapeutic circumcision on non-consenting male children.

More will be said today and beyond. Much of it will be uncritical regurgitations of the AAP’s revision by news organizations. There will also be analysis from those who recognize and highlight the glaring deficincies and oversights in the policy. I expect to contribute my own thoughts. For now, I’ll highlight one key aspect from my initial read-through before going into what I think is a more important consideration to this apparent-but-not-really temporary setback.

The short version of the statement ends with this (emphasis added):

Parents ultimately should decide whether circumcision is in the best interests of their male child. They will need to weigh medical information in the context of their own religious, ethical, and cultural beliefs and practices. The medical benefits alone may not outweigh these other considerations for individual families.

That’s so close to the ethical stance. Remove families and focus on the individual and it would be ethical¹.

The way the promoted portion of the new “finding” within the revised statement differs from this conclusion is the key takeaway to challenge the supposed change from the AAP, which is really more-or-less just an exercise in urging politicians to permit circumcision on Medicaid. Here, the AAP demonstrates that its evaluation of the net benefit, that possible benefits outweigh the risks, is subjective and determined only by individuals. This directly contradicts the supposed proof based on their review of research that the potential benefits outweigh the risks (and the costs – the direct harm in every case – that they ignore). We should repeatedly emphasize that as often as necessary.

My concern is that we’ll get stuck in this low-level, short-term portion of the larger debate. It’s clear from European medical associations and courts that the eventual destination is public policy against non-therapeutic circumcision. The AAP and American society, in general, are (inexcusably) behind. But both will get there. Activists for the rights of children can make that happen sooner than it otherwise might happen.

The key is that we must give people the opportunity to save face, to avoid digging in to protect their egos. The problem is their stance, not necessarily their character. It should be obvious to them that their stance is incorrect. It isn’t. To address that, do we want to express an irrelevant, limited sense of superiority or convince others that we’re correct because facts and ethics demonstrate the case we’re making? If we impugn their motives and/or character by choosing the former, we may extend the period during which this policy statement stands or encourage people who can be influenced either way to choose the inferior stance of the AAP.

Edit note: I changed “it’s” to “their stance” to avoid possible confusion.

¹ The existing societal view treats certain basic human rights – for boys only – as a buffet from which parents may pick and choose for their own reasons. This is the problem merely expressed within the AAP’s policy statement.

Flawed Circumcision Defense: Yair Rosenberg, Part 2

In response to the AAP’s pending release of its revised policy statement on non-therapeutic male child circumcision, Yair Rosenberg repeats the mistakes in his prior analysis. He perpetuates appeals to authority, omits relevant information, and ignores inconvenient facts. One might even say he’s being obscurantist.

This isn’t just an issue of religious freedom—it’s a basic question of public health. That’s because according to the National Institutes of Health and the World Health Organization, among others, circumcision is one of the global health community’s best HIV prevention techniques. As Eric Goosby, the U.S. AIDS coordinator, has said, “Male circumcision is a highly significant, lifetime intervention. It is the gift that keeps on giving. It makes sense to put extraordinary resources into it.” To that end, anti-AIDS organizations are partnering to circumcise 20 million African men by 2015. …

Until now, the scientific consensus surrounding circumcision has driven policy in Africa, but not the United States. Today, that changes.

Individual humans make up “public health”. What is – and is not – acceptable to do to individual bodies in the name of public health is the question of ethics that Rosenberg, Goosby, the AAP, and every other circumcision advocate ignores. This is especially true because circumcision is not the least invasive or the most effective method available for reducing HIV (or any other) risk. It’s also still not particularly useful in contexts outside of parts of Africa. As I wrote in my prior post, the risk reduction is in female-to-male HIV transmission in high-risk populations. That isn’t compelling within the scope of the AAP’s focus. Context matters. Obscurantist journalists ignore that.

The importance of this [updated policy] cannot be overstated. …

It can be. Rosenberg’s post is proof.

… The AAP is a driving force behind health policy in America, and the experts involved in its new statement are already going on record in major media outlets to advocate that circumcision be covered on public health plans like Medicaid. The statement solidifies the scientific consensus behind the advisability of infant male circumcision (noting that complications are more likely to arise when the procedure is performed later in life) and places the traditional practice squarely within the realm of sound medical science.

This is only true if ethical considerations are not a part of sound medical science. It’s fine if Rosenberg or others do not wish for ethics to be applied to their own bodies. But not everyone shares that odd, limited view. Some of us appreciate the basic concept of human rights, including those of physical integrity and self-determination, and wish they had been applied to us. It’s too late for too many males, but there is never a bad time to stop violating human rights.

Also, the question of possible benefits and their applicability to any particular individual is separate from the public policy question of paying for non-therapeutic surgical interventions on non-consenting individuals. Non-therapeutic infant circumcision is an irresponsible use of funds in pursuit of subjective goals via unethical means. There is nothing good about it, regardless of how “prestigious” an organization promoting the idea is irrationally perceived to be. An organization that advocates violating human rights deserves no prestige.

This is not just good news for the United States, where obscurantist anti-circumcision groups have sought to completely ban this medically beneficial practice rather than allow families to choose whether to perform it. …

Rosenberg’s prior essay was obscurantist propaganda. Unlike his writing, I’ve acknowledged the arguments offered in favor of circumcision. I’ve explained why they’re inferior in the debate as it pertains to individuals. Mr. Rosenberg has not done the same. Instead, he offers condescending evasions:

… It’s also a powerful rebuttal to the flawed reasoning of the German court in Cologne, which ruled that circumcision generally constitutes “bodily harm,” yet made allowances for circumcisions performed for “medical reasons.” Thanks to the AAP, we can now state that all circumcisions are medically beneficial. …

The German court in Cologne ruled that non-therapeutic circumcision on non-consenting children violates their rights to physical integrity and self-determination. There is no flaw in that expression of basic human rights. The are the same rights that form the basis for prohibitions on FGC/M.

The court’s finding that circumcision constitutes bodily harm, no quotes, is consistent with permitting circumcision for medical need. The existence of a problem necessitates considering interventions. Ethically proxy consent will choose the least invasive, most effective solution. That is rarely circumcision when there is a need. But where it is necessary, the goal is an objective net benefit, that the surgery will remedy the problem. The outcome is presumed to outweigh the harm imposed to achieve it. The key is the outcome can be measured immediately and directly. Is the malady resolved?

With non-therapeutic circumcision, there is no objective net benefit because there is no malady. There is only objective harm for subjective benefits. The subjective benefits may not be valued or desired by the individual. In that case it’s objective harm to the individual for the subjective preferences of another. That is unethical. Because surgery on children involves proxy consent, medical need is required. The court was correct and consistent. The AAP is incorrect and encouraging unethical rights violations.

So, can we really state that all circumcisions are medically beneficial? Including the ones where the boy suffers a complication? If he loses his glans, is he still benefited? What about his entire penis? What about the thankfully rare instances where the boy loses his life? At least the benefits accrued over his short lifetime? Since all of these scenarios happen, even if we ignore my focus on individuals who suffer only the expected harm, isn’t it a bit obscurantist to state that all circumcisions are medically beneficial?

… If German courts continue to prosecute Jews and Muslims for practicing circumcision, then we will know that this animus is rooted not in science or fact, but in ignorance and prejudice.

I won’t say I expected his screed to end with something other than a preemptive ad hominem attack. It’s still pathetic.

Update: Walter Russell Mead uncritically endorses Rosenberg’s flawed post and makes a request:

Hopefully anti-circumcision zealots will take a deep breath and rethink their fevered stance on the issue. Beyond the fact that their bans impinge on the rights of Jews and Muslims to practice their religion as they see fit, they ought to consider that there is legitimate science pointing to the practice being beneficial to infant male health.

The only legitimate science involving infants is on UTIs, and possibly penile cancer. The former are uncommon in intact males in the first year (1%) and almost always easily treatable. The latter is more reasonably associated with other causes, with U.S. rates similar to those in mostly intact Europe. Everything else involves adult volunteers. The possibility of health benefits, or even religious benefits, does not render non-therapeutic circumcision on a child ethical.

No court in the United States endorses a right to practice one’s religion as members “see fit”. There are limits that may be imposed based on constitutional tests. Non-therapeutic child circumcision should fail that test because it is physical harm.

Infant Male Circumcision and Current Human Rights Disparities

Another focused post for a story on which I’ll have more to say.

In a study published Monday in the Archives of Pediatric and Adolescent Medicine, a team of economists and epidemiologists estimated that every circumcision not performed would lead to significant increases in lifetime medical expenses to treat sexually transmitted diseases and related cancers — increases that far surpass the costs associated with the procedure.

I strongly suspect the study is flawed because it makes estimates. I’ll withhold further comment until I know more. For now, there’s enough to discredit the embarrassingly incomplete approach used to justify the study and its estimates.

That sentiment [that Medicaid should cover non-therapeutic child circumcision] was echoed in an editorial accompanying the study. UCLA health economist Arleen Leibowitz wrote that by failing to require states to cover circumcision in Medicaid plans, the U.S. reinforces healthcare disparities.

“If we don’t give poor parents the opportunity to make this choice, we’re discriminating against their health in the future,” she said in an interview. “If something is better for health and saves money, why shouldn’t we do it? Or at least, why shouldn’t we allow parents the option to choose it?”

We shouldn’t do it or allow it because non-therapeutic genital cutting on a non-consenting child is unethical. Male circumcision on a healthy child violates his basic human rights to bodily integrity and self-determination. It is indefensible, even if it’s possibly “better” for his health in someone else’s subjective evaluation or because it saves money when individuals are considered statistics rather than human beings with their own rights and preferences.

The abstract makes it clear the study is speculative. Yet, we already have rights-based law for females without absurd exemptions we refuse to touch for males, so the idea that rights trump speculative benefits isn’t foreign. The ability to do something or to possibly achieve some population-level result without concern for the individuals involved cannot – must not – be viewed in a bubble that contains only the factors one is interested in (e.g. male circumcision is currently practiced, so it’s acceptable).

There are no doubt many non-therapeutic surgeries we could perform on children that might result in some decreased prevalence of disease x, y, or z. Infant mastectomies to remove breast bud tissue might reduce the risk of breast cancer. Shouldn’t we study that, at least, since it might reduce cancer? Reducing cancer is “good”, whatever the means, right? No one is foolish enough (yet?) to think such a thing, which highlights the flaw in thinking by those making excuses for circumcision, such as Ms. Leibowitz here. Society should stop ignoring the costs to the individual who must bear the outcome of the decision. Ignoring them is unacceptable. The ethics of circumcision are not divisible from any other basic human rights consideration or proper medical analysis based on therapeutic need, or lack thereof.

Finally, that non-poor families can afford to violate their children’s sons’ rights is not a reason to use taxpayer funds to let poor parents violate their children’s sons’ rights. That’s a political question rather than a medical question. It is inexcusable to sacrifice the bodies of male children (only!) because we’re too cowardly to honestly evaluate the mistake of non-therapeutic circumcision on non-consenting individuals. This is the same idiotic approach Dr. Edgar Schoen pushed in his 2005 propaganda book, “Ed Schoen, MD on Circumcision”. Somehow, not using public funds to violate a child’s body and rights is discrimination. It isn’t because circumcision is not a valid parental choice. UCLA health economist Arleen Leibowitz is wrong.

None of this is a surprise, based on the editorial by Ms. Leibowitz and Katherine Desmond, “Infant Male Circumcision and Future Health Disparities”. The first two sentences reveal so much.

The health benefits of male circumcision (MC) have been extensively documented in observational studies and by randomized controlled trials in Africa showing that MC reduces heterosexual transmission of human immunodeficiency virus (HIV) infection from women to men by 55% to 76% …

The trials showed that voluntary, adult male circumcision reduces female-to-male HIV transmission in high risk populations with a heterosexual epidemic and a low rate of circumcision among adult males. That’s quite different, since it doesn’t describe the United States. It also fails to describe the circumcision they’re advocating. Children are not adult volunteers. That’s the ethical flaw in their analysis.

… and provides significant protection against human papillomavirus infection. …

Gardasil is approved for girls and boys. Circumcision is unnecessary for this possible benefit, as it is for nearly every possible benefit.

… Male circumcision is negatively associated with prostate cancer in men and with cervical cancer in female partners of men infected with human papillomavirus.

Negatively associated. Correlation is not causation. The study’s authors acknowledged this when they stated that it was an observational study. “Negatively associated” is not sufficient.

Flawed Circumcision Defense: Charlotte Allen

Charlotte Allen has an editorial in today’s Los Angeles Times about circumcision and intactivists. She doesn’t understand either. She begins:

The “intactivists” — anti-circumcision people who are trying to get the practice outlawed in the U.S. and elsewhere — …

This is off to a terrible start. The effort is to prohibit non-therapeutic circumcision on non-consenting individuals. That’s an ethically significant difference. While I suspect she thinks that her words mean what I just wrote, they don’t. Her claim is what’s being repeated, as if this effort is the same as seeking a complete prohibition on religious circumcision for everyone of any age. When arguing against something, the first requirement is to fairly and accurately state the opponent’s position. She fails at that in the first half-sentence.

Intactivism, a movement of the last 20 years or so, got a boost recently when a German judge ruled that non-therapeutic circumcision of children amounted to “bodily harm” and must henceforth be outlawed. …

First: intactivism in its current form has been going on for at least twice as long as she claims. (e.g. Van Lewis)

Re: the court’s ruling. The issue of bodily harm, which is objective, appears only here. She will not directly address this again. She mentions sensitivity, as though that’s the extent of possible harm, and draws an incorrect conclusion by selectively quoting a press release. (More on that in a moment.)

The tagline attached to Ms. Allen’s essay is this:

‘Intactivists’ are trying to get the practice outlawed in the U.S. and elsewhere. But how bad can it be?

There is bodily harm in every circumcision. But to the question, it can be very bad. This bad. Or this bad. Or the worst case scenario. Those are thankfully rare, but they occur. Those males are (or were) individuals with human rights. They are not merely statistics to ignore.

The intactivists like to paint circumcision in lurid colors. The phrase they use to describe it — “male genital mutilation” — evokes the barbaric practice of female genital mutilation. But the two have almost nothing in common. …

Mutilation is an accurate description for non-therapeutic male circumcision without the child’s consent. And it has considerably more in common with female genital mutilation than Allen understands.

She continues:

… Female genital mutilation is invasive and ghastly, and results in long-term health risks for women subjected to it, not to mention the diminution or elimination of the ability to feel sexual pleasure. …

Usually, yes, but that doesn’t justify male circumcision. As I’ve said elsewhere, a punch to the face is not acceptable because a knife to the gut is worse. The difference should be in punishment, not prohibition.

Apart from the valid aspects of the comparison of non-therapeutic genital cutting on a non-consenting individual, male or female, male circumcision is unethical on its own.

Male circumcision involves snipping off about three-eighths of an inch of skin. It hurts, briefly, but so do the shots that babies routinely receive. And according to the World Health Organization, it “reduces the risk of heterosexually acquired HIV infection in men by approximately 60%.”

That three-eighths of an inch of skin will grow into a larger structure if left in place. It also removes the nerve endings within that three-eighths of an inch, and leaves a scar. But with that argument, the clitoral hood, or even the clitoris, is a tiny structure in infants. Does that render it ethical to remove either of these from a healthy infant? She’s offering a ridiculous defense of non-therapeutic genital cutting on a non-consenting individual.

For the HIV statistic, she cites this page. She failed to quote pertinent information beyond the first sentence. She should’ve included the part that says “male circumcision should be considered an efficacious intervention for HIV prevention in countries and regions with heterosexual epidemics, high HIV and low male circumcision prevalence.” Not one of those three criteria matches a Western nation. It isn’t compelling. Citing it as a justification for infant circumcision is an empty defense, which is worsened by additional arguments against this reason for circumcising infants. (Anything other than circumcision with the voluntary consent of the individual where those scenarios apply is still unethical.)

The notion that circumcision reduces a man’s sexual sensitivity has little basis in fact. Two medical studies, in 2003 and 2007 — one presented to the American Urological Society and the other published in the Journal of Sexual Medicine — found that circumcised and uncircumcised men experienced the same levels of response to touch and pain during sexual arousal. A press release issued by the 2007 study’s chief researcher, at McGill University in Montreal, stated: “This study suggests that preconceptions of penile sensory differences between circumcised and uncircumcised men may be unfounded.”

Suggests is not a synonym for proves. Allen seems to possess a tendency to consider only what is convenient rather than presenting all facts. This press release from McGill University about that study includes the following caveat:

Payne cautioned that though the study’s results are very promising, they are still preliminary and do not necessarily resolve many of the longstanding controversies surrounding circumcision. “This study only measures one sensation, so it questions the held notions, but it does not refute the idea that there may be some differences at some level. No one can deny the anatomical differences between a circumcised and uncircumcised penis.”

To be fair, it’s possible that the version she read didn’t include that caveat. I’m not sure why a press release from these scientists wouldn’t include such a caveat, but I don’t know what her source is. However, a simple bit of thinking reveals the inherent flaw in drawing such a broad conclusion from research like this. This basic fact can be confirmed by reading the study itself:

… 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. …

To state the obvious: the foreskin is removed during circumcision. Comparing that in circumcised men is impossible. The study does not demonstrate what Allen claims it demonstrates.

It’s obvious that Allen has not considered anything beyond her limited understanding of circumcision. At best, she presents lazy thinking with minimal research. Or worse, she started with her conclusion and created a fortress around her mind to protect myths and block facts. Whatever the reason, she is wrong. Her defense of non-therapeutic circumcision on children is pathetic.

**********

Post Script: Unsurprisingly, more errors exist in Allen’s analysis. I included them in the original version of this post. I deleted them because they weren’t egregious in the way the above excerpts are. I’ll include one bit in the comments. The above is what I think should be the critical argument against her propaganda.