Category: Public Health

The Core of Public Health Circumcision Promotion

From the awful WHO Fact Sheet, “Voluntary [sic] medical male circumcision for HIV prevention” (bold added):

In line with global goals such as Millennium Development Goal 6 to halt and reverse the spread of HIV and the WHO Global Health Sector Strategy on HIV/AIDS, a five-year Joint strategic action framework to accelerate the scale-up of voluntary medical male circumcision for HIV prevention in Eastern and Southern Africa 2012-2016 was developed by WHO and UNAIDS with the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the Bill & Melinda Gates Foundation and the World Bank and in consultation with national ministries of health. The framework calls for an intensified response by countries and partners to ‘catch up’ with men 15 to 49 years old who were not previously circumcised and to establish sustainable services for infants and adolescents for the longer term. The framework promotes country ownership, a combination of approaches and strategic, coordinated action.

Infants and adolescents don’t consent. This indicts WHO, UNAIDS, PEPFAR, the Bill & Melinda Gates Foundation, and the World Bank. They are all directly complicit in the violation of basic human rights in Africa. They are also propagandists willing to use a word (“voluntary”) that they have no intention of following.

Always Ignoring Voluntary and Adult

As always, when public health officials discuss voluntary, adult male circumcision, they never mean voluntary or adult. Never:

ZIMBABWE is planning to expand its circumcision campaign to include newly-born babies as part of the country’s fight against the spread of HIV and AIDS, a senior health ministry official has confirmed.

The ministry’s AIDS and TB unit co-ordinator, Getrude Ncube, said a pilot project targeting babies between one and 28 days old would be launched before year end with the full programme likely to be rolled out in 2014.

They dress it up in nonsense.

“Although circumcising neonates will not have an immediate an impact, results will show in 20 years’ time. Our sole aim is to try and reduce new HIV infections.”

No, the sole aim is to implement circumcision. They believe their intentions are noble, a fact I do not doubt. But if their sole aim is to try to reduce new infections, they’d focus limited medical resources on those currently at risk of sexual transmission. They’re not, unless we stupidly assume all males aged 15 to 49 in Zimbabwe have been circumcised. Instead, they’re shifting to males who can’t consent. They still have 500,000 males to circumcise before 2015 to reach their target. The target is what matters, not the individuals being targeted.

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.

More on the Fallacy of VMMC: Infant Volunteers

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

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

Providing VMMC Services

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

Costing and Impact Summary

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

The key policy topics addressed by the model are:

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

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

  • …

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

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

Medical Male Circumcision

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

  • …

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

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

4.2.2 Voluntary medical male circumcision (VMMC)

Evidence

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

Program Implementation

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

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

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

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

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

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

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

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

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

**********

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

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

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

Flawed Circumcision Defense: Mitchell Warren

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In its Uganda findings (page 55):

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Duty to Run Interference

Author John Scalzi posted an essay on his blog, Whatever, from an unnamed friend who is a doctor. It discusses the recent furor over the political push for transvaginal ultrasounds mandated for political “need” rather than medical usefulness. The essay is well-worth reading. I wish to post an excerpt relevant to my purpose for Choose Intact because it involves a doctor’s responsibilities in medical intervention. The doctor is concise, specific, and irrefutable. The logic is as applicable here as it is in non-therapeutic transvaginal ultrasounds.

It is our responsibility, as always, to protect our patients from things that would harm them. Therefore, as physicians, it is our duty to refuse to perform a medical procedure that is not medically indicated. Any medical procedure. Whatever the pseudo-justification.

It’s time for a little old-fashioned civil disobedience.

And from the doctor’s proposed step two to protect patients from such legislation:

Our position is to recommend medically-indicated tests and treatments that have a favorable benefit-to-harm ratio… and it is up to the patient to decide what she will and will not allow. Period. Politicians do not have any role in this process. NO ONE has a role in this process but the patient and her physician. If anyone tries to get in the way of that, it is our duty to run interference.

An excellent summation of the physician’s responsibility to his/her patient.

Further Thoughts on Dr. Diekema’s Recent Statements

Now that I’ve rebutted the possibility of a revised AAP position that more favorably supports non-therapeutic infant circumcision, I want to comment on a few additional statements from the interview with Dr. Doug Diekema.

Diekema is aware that there is a movement of “intactivists,” or people who believe that it’s wrong to cut off part of a baby’s body if not medically necessary. “I get huge mailings with FedEx boxes, summaries. I do look at it — I have a file of all of that — but I am not about to let them do the evaluation for me.”

I agree, he shouldn’t substitute anyone’s evaluation for his own. But he should evaluate everything, including the implications of a policy to the individual he acknowledges who might not want that policy applied to his body, permanently. Merely citing the ethical conundrum without drawing a conclusion in favor of the patient, or drawing a conclusion that some possible benefit preferred by someone else for a minor risk justifies setting aside a basic bodily right everyone possesses, is unacceptable.

Diekema said that “hundreds of papers were reviewed and judged for their quality” and that people from the anticircumcision camp “will quote you all kinds of studies — which were frequently terrible and didn’t prove anything because they were so methodologically flawed.”

This is a problem. We should all strive to be logical and accurate. That’s why I don’t cite certain sources and statistics seemingly in favor of my position.

On the other side, it’s also problematic to quote the statistics derived from voluntary, adult circumcision in Africa and apply them to forced circumcision of healthy infants in America. The HIV epidemic is fundamentally different in the two populations. And citing the impressive relative risk reductions without honestly dealing with the unimpressive absolute risk rates and reductions is flawed, as well. This also ignores whether or not the male would prefer an increased risk of HIV transmission from his female partner(s) in high-risk populations. Dr. Diekema acknowledged that not all men would make this trade.

“They don’t like what we’re doing. I get hate mail from them all the time, trying to paint what we’re doing as pro-circumcision. I am conflicted about circumcision personally. It’s a hard choice; it’s a hard decision, and there are good reasons for almost any decision you want to make.” He described his task force as “a moderate group — not pro, not anti. We’re trying to uncover what’s real here.”

It’s not a hard choice. There aren’t good reasons. What’s real here is that the child is healthy. No surgery is indicated. That’s a basic point that should be easily understood and universally applied. That’s the entire discussion. The AAP should declare that non-therapeutic child circumcision should cease immediately.

He said that circumcision removes “maybe 1/3” of the skin on a male’s penis but said that may or may not affect sexual experience. “What you really want to know — ,” he says, “it’s fine and dandy to say circumcision removes all kinds of nerve cells, but more nerves doesn’t necessarily equate to more pleasure — so what you really want to know but can’t look under a microscope and get the answer is: How has the sexual experience changed?”

Ultimately, “we don’t have any good data. Circumcised men may experience sex differently than uncircumcised men — intuitively that makes sense — but it’s simply not the case that we have an epidemic of uncircumcised men that don’t get pleasure or can’t function sexually.” When some men who were circumcised as adults in Africa were asked about the change in sexual function, Diekema says, “most men reported no difference — a small percentage report that it’s worse, and a small percentage report that it’s better. There’s such a psychological component.”

Of course it may or may not affect sexual experience. Human sexuality is complicated, with as many preferences for experiences as there are people. That alone should be enough. The males who would prefer to have their foreskin for its sexual purposes have their preferences superseded by their parents’ preferences. That’s not ethical.

But we already have the answer to a simpler question, whether or not the sexual experience changes. There was a foreskin before circumcision. There isn’t a foreskin after circumcision. That alters the sexual experience. Whether or not that is good or bad is a decision for the male affected, not his parents. The exclusive input on the psychological component is the male who owns the foreskin, not his parents. It doesn’t matter what they think about how circumcision affects – or should affect – his experience. Dr. Diekema said it himself. Not everyone would trade their foreskin. There is only one valid position on this topic.

Quoting Dr. Doug Diekema Against the AAP’s Position

There’s been some mystery about why the AAP has taken so long to issue its revised statement on routine infant circumcision. It was expected years ago but still hasn’t been released. I won’t speculate on why this delay continues. Instead, we must look at the only new piece of information, a bit of insider speculation revealed this week. Deirdra Funcheon interviewed task force member Dr. Doug Diekema for the Broward Palm Beach New Times.

“Your frustration is shared by many,” Diekema said. He said that it had been hard to coordinate schedules of the busy task force members but that they had finally completed an exhaustive review of all relevant studies, and now “our work is 95 percent done. To my knowledge, the [new] statement and technical report have been drafted and are being reviewed by other members of the task force. We expect that this will be released sometime this spring.” Said Diekema: “Our starting point was the existing policy statement from 1995, which took a fairly neutral stance — it said there were modest medical benefits and some risks. Since then, data has been generated that might alter that recommendation. It’s fair to say that there are much more clear medical benefits than there were at the time of the last report, although no radical change in the data regarding risk. I expect that the academy will come out with a somewhat stronger statement.”

I don’t think “somewhat stronger” suggests a statement that will say anything close to “everyone should circumcise their sons”. That’s a guess, but if the task force was determined to say that because they feared parents leaving their sons intact was any real danger to the boys, they’d work harder to coordinate their schedules. They didn’t. Still, any inching toward a more positive statement would be indefensible, because the statement should be stampeding to the ethical position, the one which removes the choice from parents and leaves the choice with its proper owner, the (healthy) child. But I suspect Dr. Diekema’s statement is less than we fear. As always we should respond to this with logic and respect. The facts are on our side.

For example:

He went on to say, “If you talk to reasonable people about what the data shows… it’s real. …

I’m interrupting his thought here to point out that “reasonable people” is a framing device intended to show that he’s serious, unlike others who reject the data. It’s pointless. Reasonable people can disagree on the data, the methodology, and the application without being insincere or propagandists.

On that point, the data also shows that almost every male has healthy genitalia at birth. No surgery is indicated. The pursuit of some possible future benefit is speculative because the child is healthy. This is as true for the normal foreskin as it is for every other body part on boys and every body part on girls. This is the ethical question improperly ignored when advocates ask us to focus on “what the data shows”. A healthy body is also science.

… [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. Parents ought to be the decisionmakers here. They should be fully informed.

There’s the ethical question improperly ignored. Dr. Diekema understands that not all males would trade that foreskin for the medical benefit. The condition he set can’t be met. Parents can’t know if their healthy son will be one of those males. They can never be fully informed. This is the beginning and end of the discussion.

Dr. Diekema is a pediatric bioethicist. If he is to adhere to the ethics his position requires, he would immediately and completely oppose any AAP statement other than a complete rejection of non-therapeutic male child circumcision. Non-therapeutic genital cutting on a non-consenting individual who may not want the surgical alteration is ethically wrong.

Consider the AAP’s policy on the ethics of female genital mutilation (while remembering the comparison is non-therapeutic genital cutting on a non-consenting individual):

The physical burdens and potential psychological harms associated with FGM violate the principle of nonmaleficence, a commitment to avoid doing harm, and disrupt the accepted norms inherent in the patient-physician relationship, such as trust and the promotion of good health. More recently, FGM has been characterized as a practice that violates the right of infants and children to good health and well-being, part of a universal standard of basic human rights.

Which parts of the emphasized sections have an exemption based on gender? It’s certainly not the pursuit of benefits that he stressed in the linked interview. Those are subjective and speculative. He has indirectly testified to this standard in court. Participating in the revision of a statement to encourage parents and physicians to behave unethically doesn’t make sense.

Rwanda Imposing a Foreskin-Free Generation

On Monday the Washington Post published a propaganda piece by Rwandan Minister of Health Agnes Binagwahois. She talks writes of “an opportunity to lay the foundation for an AIDS-free generation,” which inevitably means a primary focus on “voluntary, adult” male circumcision. It’s a matter of faith that this will solve everything, and as a result, there must not be any ethical issues to discuss. Anyway, they’re only implementing “voluntary, adult” male circumcision. Just believe.

Experience demands a closer inquiry. When public health officials speak of “voluntary, adult” male circumcision, they never mean voluntary or adult. They say it, as Binagwahois does. That phrase is mandatory. They do mandatory very well.

We have the capacity to save nearly 4 million lives in sub-Saharan Africa, the hardest hit region in the world, by scaling up voluntary medical male circumcision — the best tool we have for HIV prevention. But the only method widely approved for funding is the surgical method, which is expensive and impractical for countries lacking physicians and surgical infrastructure.

She didn’t say adult yet, but that shows up. She writes that “[p]ublic health officials set a goal to reach nearly 20 million men ages 15 to 49 by 2015…”. I’d quibble over a 15-year-old being an adult, but I also think a 15-year-old is capable of informed consent. If only her statement were true.

In the essay she links to a paper outlining Rwanda’s “national goal”, which can be summed up as a willful violation of human rights. From page 61:

High coverage of male circumcision has been shown to be effective in reducing heterosexual transmission of HIV infection. Under this Outcome, circumcision will be promoted to adult males, with the aim of increasing the prevalence of circumcision. In addition, although circumcision of newborn boys will not contribute to the result of reduced sexual transmission of HIV during the period covered by this NSP, it is nonetheless an important long-term strategy for reducing susceptibility to HIV infection in the Rwandan population.

In case it isn’t quite clear enough, the report includes this table:

Figure 18

Then it’s summarized:

Output 1.1.2.1. Newborn boys, adolescents and adults have increased access to circumcision

Key strategies:

  • i. Advocacy for integration of circumcision in minimum package of health centers
  • ii. Promotion and provision of male circumcision for adolescents and adults
  • iii. Promotion and provision of male circumcision for newborn boys

She also links to the WHO’s 2011 revised report, Progress in scale-up of male circumcision for HIV prevention in Eastern and Southern Africa: Focus on service delivery. On page 14 the WHO describes Rwanda’s current “Service” delivery strategy.

Plans include the integration of MC into existing services with campaigns and mobile services to increase coverage. Service delivery has begun at selected sites, including military settings. Neonatal and adolescent MC is articulated in the longer-term plan.

About that “long-term” plan. Rwanda keeps saying “long-term”, but a close look at Figure 18 shows its definition. Rwanda’s target for 2012 is 50% of all newborn males. Rwanda is actively circumcising newborn males now. The limitation is clearly not intent. I believe they are sincere in focusing on adults, although less so on the “voluntary” aspect. But it’s obvious where the real focus is. Fear of HIV in the presence of effective-but-elective non-surgical interventions leads to a blatant disregard for the rights of children. It is disgusting.

Since there is a national plan to circumcise newborn and adolescent males without their consent, why does Binagwahois not say so explicitly? Instead, she pretends that the current focus is only on adults and limits herself to advertising for the “non-surgical” PrePex device. Since she doesn’t know the meaning of voluntary or adult, it isn’t particularly surprising that she doesn’t understand the definition of surgery. The ability to limit bleeding does not mean it is non-surgical. Condoms are non-surgical. Foreskin removal is surgical. It’s not refuted just because the device’s manufacturer says so. Regurgitating marketing material is not supposed to be the job of a public health official.

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For consideration relevant to the ethics and practicality of the PrePex rollout, Figure 6 in the study (NSFW) Binagwahois’ essay links suggests to me that there will be complications when use of this device is scaled to 20 million men in field settings. And to be fair to Circ MedTech, it promotes PrePex for adult male circumcision. We’ll see if their focus remains on voluntary, adult male circumcision.