Category: Mission

The Circumcision Decision

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

We Must Do Better

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

Flowchart1_resized

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

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

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

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

P.S. Shut up also needs to go.

The Case Against “The Case Against Intactivism”

If you’ve read my work here (or on Twitter) for any length of time, you know that I don’t agree (e.g.) with every tactic used to argue for genital integrity. I’m not arrogant enough to assume I’m always correct, but my experience has to inform the means I endorse in pursuit of the necessary, noble goal. Where I think we’re making mistakes, particularly predictably ineffective mistakes, I speak out. I know enough people within the genital integrity movement to know that the principled, decent strategy is the most common.

That said, I’m not willing to paint broadly based on the actions of individuals. This can be either good or bad actions. One person expressing an idiotic excuse for circumcision do not mean everyone who shares a characteristic would defend that excuse. I do this because it’s fair and because I do not want this approach applied to me. It will always be possible to find genital integrity activists who engage in inexcusable behavior, such as anti-Semitism. I can make my case without that, as can most activists. Principles and tactics are associated, but the former exists apart from the latter.

This is why the website The Case Against Intactivism frustrates me so greatly. It is run by blogger “paper0airplane”, who is against routine infant circumcision while lumping any bad behavior by those opposed to circumcision into the “intactivism” category. This is wrong. For example, I spoke out when issue #2 of “Foreskin Man” appeared, long before it made news during the San Francisco ballot initiative in mid-2011. I was not alone. Should we all be blamed for this comic book, or are individual – sometimes egregious – mistakes inevitable in any decentralized movement? The answer is obviously the latter, but paper0airplane consistently writes as if it’s the former. That is what I wish to reject here.

In July paper0airplane posted this:

… My opinion also hasn’t changed. I do not circumcise, I don’t think circumcision is necessary. I also do not approve of the tactics used by intactivists, and were they to change those tactics, I would support them wholeheartedly. Much like the rabid pro-life crowd, intactivists generally resort to appeals to emotion, twisting of facts, offering up studies (that they haven’t even read) claiming they say one thing, when in fact they do not (relying, instead, on the fact that many will not actually read the study, simply providing one counts as support of their argument), sometimes outright lying. That includes setting up studies in such a way as to pre-determine the outcome. These are things that I disagree with, and will continue to disagree with. Since most intactivists, instead of actually reading my site objectively, believe that I am actually pro-circumcision and that my site advocates for circumcision, I’m attacked quite often. …

People who can be classified as intactivists cannot be neatly stuffed into a box labeled “Endorses These Tactics”. I am an intactivist, although what I wrote in 2006 still holds. The term intactivist is cute and descriptive, but because it’s cute, I do not like it. It does little more than give reporters an excuse to fill in stories with details at which typical readers will roll their eyes. That’s not helpful. The term has gained wider acceptance, but it’s still treated in much the same way in many places. And paper0airplane uses it as a convenient stereotype.

So, from that July post, in order:

  • Generally suggests stereotyping. That should be a signal that the critique is shaky. Not necessarily flawed, but evidence is required and should be drawn from and applied to the person(s) using the criticized tactic.
  • Appeals to emotion as a tactic is the least effective approach. Those who use it exclusively need to expand their repertoire. But its use, even exclusively by some, says nothing about intactivism as a whole.
  • I do not twist facts. Grinding this axe with a blunt dismissal of all rather than against the few who deserve it impedes my efforts. If paper0airplane insists on grouping everyone together, prove that I’m the hack caricature with examples. Otherwise, I’m left to assume that paper0airplane is a lazy thinker and writer. (The body of work that assumes any intactivist is all intactivists is evidence of this.)
  • I do not defend studies I know to be flawed. I’ve long held that the “estimated number of deaths” study is flawed¹. Conversely, I’ve also demonstrated that the “circumcision makes no difference to sexual sensitivity/satisfaction” studies are flawed. Should this count as an argument against all proponents of child circumcision or just those who fallaciously treat this issue as settled science based on these flawed studies? There are proponents who are very much lying propagandists. There are also proponents who are sincere and honest but insufficiently informed. I prefer to deal with who is in front of me rather than the worst of everyone I’ve ever encountered.
  • I’ve read enough to know that paper0airplane is opposed to routine infant circumcision. I also know that paper0airplane defends ritual circumcision. I disagree with this because the arguments against non-therapeutic circumcision, both ethical and scientific, apply to males born to religious parents. I do not wish to imply that change will be easy, only that change is necessary, as various reforms throughout history have been necessary. We are not at the pinnacle of balancing religion and rights. (More on this in another post.)

Going back to paper0airplane’s first post, this:

There are many many very reasonable people that label themselves intactivist. They’re nice people are are just as interested in the truth as you or I. Unfortunately, the loudmouths at the front are doing all the damage. They color public perception of what intactivism is. I think we can greatly reduce the number of circumcisions without being total A-Holes or alienating all our circumcising friends and family. Without being bullies. Because that’s what intactivists are represented by. Bullys. To the reasonable people that label themselves intactivist, I beg you! Find another way to label yourself! People will be more likely to listen if you don’t have to carry the intactivist baggage around.

This paragraph demonstrates my point. There are intactivists who use problematic and/or unethical tactics. Again, this is inevitable in any decentralized movement, just as one can easily find examples of the same among circumcision proponents. It’s possible to challenge, refute, and/or discredit “the loudmouths” without dismissing everyone by stereotyping on the behavior of a subset. I wish paper0airplane would make that effort instead of indiscriminately smearing good and bad activists as the same.

¹ While this study is not something I trust or cite, the number of deaths from non-therapeutic child circumcision is objectively non-zero. That is a fact. How many deaths from non-therapeutic genital cutting on a non-consenting minor do we need before we can demonstrate the ethical case against prophylactic child circumcision? The mere risk of one is enough, but one death is certainly too many. I suspect paper0airplane agrees, although that makes the accompanying defense of religious circumcision of children indefensible. Ritual circumcision of minors is no less an affront to human rights than cultural circumcision.

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.

Same-Side Advocacy

It’s probably clear by now that some portion of my advocacy here attempts to reach people with whom I agree. We all have much to learn from each other about how to educate and convince people who do not yet accept our position. We must be intelligent in our tactics as activists if we are to be effective at changing minds and protecting children.

I introduced a bit of economics in the past to explain our position. We can learn from other fields where they provide relevant lessons, such as the truth that circumcision has costs in addition to the claimed benefits (i.e. “no free lunch”). I think this post by economist Arnold Kling is applicable, as well.

The following thought occurred to me recently. Suppose we look at writing on issues where people tend to hold strong opinions that fit with their ideology. Such writing can

(a) attempt to open the minds of people on the opposite side as the author

(b) attempt to open minds of people on the same side as the author

(c) attempt to close minds of people on the same side as the author

So, think about it. Wouldn’t you classify most op-eds and blog posts as (c)? Isn’t that sort of pathetic? …

That seems correct to me. I strive for (a) and (b). I try to avoid engaging in (c), although I don’t know that I possess the distance necessary to evaluate my results objectively. Later in his post, Mr. Kling writes:

…Focusing on weaker arguments instead [of the strongest arguments of opponents] is a classic (c) move. …

I challenge weak arguments in favor of non-therapeutic child circumcision because they’re so prevalent. I (mostly?) avoid repetitive attacks because it’s not necessary. I try to blog about them only when the author uses a novel approach to push a wrong idea, or has significant attention that risks spreading nonsense further.

Still, I take the point. It’s too easy to pretend that all arguments arguing in favor of non-therapeutic child circumcision are equally weak. Unconvincing, yes, but that’s not the same. I’m sure I’ve fallen into this trap in some of my posts. I’ve been thinking on this lately, and especially now in response to the German court ruling. There are issues offered by proponents of ritual child circumcision that deserve to be taken seriously. Asking people to let go of something they intensely value is asking them to bear costs, even if it should be clear that avoiding objective harm to the child must be stressed more. I intend to write more on them in the near future.

We should all strive for more (a) and (b), and on the tougher arguments. The first link above does that. Most of us strike the right balance between strident activism and basic decency. We must remember that, even in the rare instances where it may not be true, those who support non-therapeutic child circumcision are not evil. They are mistaken, and we should show that. But it is both unethical and unwise to demonize anyone. And, specifically, it would be wonderful if we all nudged our fellow activists from (c) to (a) and (b) where we encounter it. (Privately, if possible.)

That includes me. If I do something wrong, whether in tactic or argument, I want people to challenge me. Help me. I want to protect children, not my ego. I believe we all do. Let us always demonstrate that approach.

**********

July 6, 2012 Update: I’ve thought a bit more about addressing the tougher questions rather than the weaker arguments of those who support non-therapeutic child circumcision. I’m more comfortable with my approach because I don’t comment on much of what I encounter. There are many simplistic or embarrassing arguments I encounter repeatedly in different places. I ignore them because challenging them here would be to engage in the criticism I agreed with above. The flaws in those arguments are almost self-evident, and they are not necessarily representative of the views expressed by proponents.

Lawsuits as Strategy Follow-Up

In what will come as no surprise, a U.S. District Judge Karen Schreier dismissed the lawsuit Dean Cochrun filed over his circumcision. (Original post) This news article reported the dismissal, although I don’t believe the facts within the article are 100% accurate.

But U.S. District Judge Karen Schreier dismissed his case last week, finding that the federal court system has no jurisdiction over such a small claim. She also ordered him to pay a $350 filing fee.

Judge Schreier dismissed the case, finding that the court has no jurisdiction. As I read the decision, she dismissed it without regard to the sum, even though the sum Mr. Cochrun requested ($1,000) was less than the $75,000 threshold. Judge Schreier wrote:

… Because Cochrun has not alleged any facts to establish he and defendants are citizens of different states in support of diversity jurisdiction, his claim is subject to dismissal. See Barclay Square Properties v. Midwest Federal Sav. & Loan Ass’n of Minneapolis, 893 F.2d 968, 969 (8th Cir. 1990) (“When jurisdiction is based on diversity of citizenship, the pleadings, to establish diversity, must set forth with specificity the citizenship of the parties.”). Thus, the court need not consider whether his complaint has met the amount in controversy requirement. Because this court lacks subject matter jurisdiction, Cochrun has failed to state a claim upon which relief may be granted.

As always the caveat remains that I am not an attorney. It’s possible – probable, even – that I’ve misread or missed something. When Judge Schreier writes that “…Cochrun’s claims are dismissed without prejudice pursuant to 28 U.S.C. § 1915(e)(2)“, I assume it’s for (iii) rather than (i) or (ii). I could easily be wrong. But I read her decision as a dismissal based on lack of jurisdiction before considering any other questions involved. Mr. Cochrun filed a federal suit where all parties reside in one state. The court didn’t need to consider the relief sought. As I read it…

The point is that this was predictable and predicted. This is not a defeat. The challenge rests in how we promoted it and how much fiction opponents will read into the decision. For the former, anyone who jumped on this in our favor should probably reflect on the cost of blind support for anything that nominally might help us. For the latter, we need to confront it wherever we encounter it. Judge Schreier’s words are clear enough to prove that she did not rule on the merits of circumcision. The take-home is that this is neither evidence nor proof in favor of any conclusion regarding non-therapeutic male circumcision on a non-consenting minor. (Given the problems with Mr. Cochrun’s lawsuit and his plan to represent himself, I think we should be happy this was dismissed on lack of jurisdiction, as expected.)

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.

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.

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.