Category: Public Health

Individual Preferences Need Not Be Cost-Effective

With an opening paragraph like this, I’m inclined to cheer:

A group of top world economists said Wednesday that adult male circumcision, a global priority for preventing HIV infection, is not nearly as cost-effective as other methods of prevention.

They’re economists. I generally expect sensible reasoning from economists, so this is good. Except, reading beyond this first paragraph reveals something unexpected:

The group told representatives of global organizations at Georgetown University that more cost-effective ways to prevent the spread of the disease are an HIV vaccine, infant male circumcision, preventing mother-to-child transmission of the disease and making blood transfusions safe.

Including infant male circumcision in that list is offensive. Like medicine there’s more to economics than just numbers. We cannot ignore the ethical human rights violation involved in non-therapeutic male child circumcision in favor of saving a few dollars.

To be fair, stating that (forced) infant male circumcision is more cost-effective than (voluntary) adult male circumcision is not an endorsement of the former. It will be read as such, and there may be some willingness amongst these economists to endorse that view. I don’t know, so I’m going assume the most charitable reading possible.

However, to demonstrate the importance of including ethics, consider a hypothetical: a bullet is cheaper than life-extending medical care for terminal patients. Is it reasonable (i.e. ethical) to state that euthenasia and suicide are more cost-effective than treatment unlikely to work without also acknowledging the very important ethical caveats in the cheaper solutions?

Consider this from the article:

A successful adult male circumcision effort would require “a large public campaign to get people into the clinic,” said Bjorn Lomborg, director of the Copenhagen Consensus Center, a Danish think tank focused on cost-effective public spending that commissioned the panel.

Getting men to volunteer to be circumcised would not be easy and “it could cause more risky behavior,” Lomborg said.

If it won’t be easy getting men to volunteer, and I think he’s correct, then it’s unethical to force circumcision on a child. Circumcising a child removes the choice from that male to have himself circumcised or not as an adult when we readily understand and accept that he won’t likely volunteer if left with his choice.

Also, to my knowledge, there has been no assessment of whether forced infant male circumcision is effective at preventing reducing any risk of HIV transmission. Assuming that infant and adult male circumcision are the same is unscientific.

Rejecting Majority Rule in Favor of Majority Rule

There is simply too much pro-infant circumcision talk within The Washington Post’s opinion sections recently to adequately address everything flawed within its pages. Instead, some quick hits.

From Dr. Mohammad A. Khalid:

In my opinion as a doctor, male circumcision should not be banned, and should not be in any way equated with female genital cutting (FGC).

He’s making a legal argument based on his medical degree. That is a logical fallacy The Washington Post shouldn’t have enabled. We don’t legally allow parents to cut their daughters’ genitals if that cutting will leave a “minor”, non-permanent wound. Legally, we know it is a violation of the child’s constitutionally-protected rights. The medical argument within the legal argument is settled once we approach the initial diagnosis of the child that any genital cutting would be non-therapeutic. Legally, there is no justifiable distinction to be made. That is the issue involved.

Later:

[FGC] is a violent procedure, often done in a primitive, non-medical setting and is mostly accomplished with crude instruments and performed without anesthesia.

Male genital cutting (MGC) is a violent procedure. That comparison works. The rest of the second paragraph doesn’t, but it proves nothing. No one would support FGC if parents have it performed in a modern medical setting with proper surgical tools and anesthetic. They shouldn’t, of course, because it’s wrong whenever it’s non-therapeutic and forced. But the principle is the same, regardless of gender: non-therapeutic genital cutting on a non-consenting individual is wrong. In this core, logical respect, Dr. Khalid is wrong. MGC equals FGC.

Next, from Dr. Aseem Shukla:

The data is mixed, there is no wrong or right answer. Families deal with the nebulous every day and make a decision that is right for their children. But to me, the inanity over the circumcision debate lies also in its ignorance of medical realities. If a child has had recurrent urinary tract infections or a lower urinary tract anomaly, circumcision can protect the child from the risk of renal damage by nearly 10 to 15 fold. If a child has a hypospadias, an anomaly where the urethral opening opens along the shaft of the penis rather than at the tip, then I will use the foreskin to reconstruct the urethra, and a circumcision results. And while my clinic is full of children, also, with partially done circumcisions, adhesions that have formed, and urethral openings that have narrowed after circumcision requiring additional surgery and health care dollars, my clinic is just as full of children with foreskin that is painfully infected, scarred with lichen sclerosis, ballooning, torn and tight that may necessitate a circumcision.. [sic]

Dr. Shukla is a voice of ignorance here regarding medical realities. If a child has recurrent UTIs, circumcision may be medically necessary. If a child has a hypospadias, circumcision may be medically necessary. The question is not “Should we treat patients who have medical needs”, but “Should we treat children who have no medical need?”. The issue at stake is non-therapeutic circumcision. Unless we start making a “logical” case for non-therapeutic appendectomy, cholecystectomy, or any other intervention that might solve some future problem, society abuses logic in defending non-therapeutic male circumcision. Even female genital cutting could be justified on the confusion Dr. Shukla creates by muddying the obvious distinction between therapeutic and non-therapeutic.

[As an aside, is it possible that some of the problems for the intact children he cites are created by premature, forced retraction of the normal foreskin by parents and/or pediatricians?]

Sticking with Dr. Shukla, he is arguing against a proposed prohibition that is not up for consideration:

… Any type of blanket ban on a circumcision until the age of consent so ignores the real medical necessities of circumcision in some cases, that the concept is beyond contemplation; it is medically irresponsible and dangerous.

The proposed law is not a “blanket ban on a circumcision until the age of consent”. It would prohibit non-therapeutic circumcision until the age of consent. Healthy children do not need surgery. Thus, it shouldn’t be imposed, even if that surgery might reduce the risk of some malady later. The only stance here that is medically irresponsible is Dr. Shukla’s. Until he reads the proposed law, he shouldn’t pontificate on his factual errors.

Next, from Charles C. Haynes, Director of the Religious Freedom Education Project:

The anti-circumcision referendum is both wrong and dangerous because it subjects religious freedom to a popular vote. As Justice Robert Jackson wrote in West Virginia v. Barnette (1943):

“One’s right to life, liberty, and property, to free speech, a free press, freedom of worship and assembly, and other fundamental rights may not be submitted to a vote; they depend on the outcome of no elections.”

Each healthy male child’s bodily integrity – his life, liberty, and property, as well as other fundamental rights – is submitted to a vote by his parents. If they vote “yes”, his rights are violated. Why should it be better that the vote belongs to his parents rather those who would protect his right to choose “yes” or “no” for himself? He is an equal individual, allegedly with the same liberty interests that his sisters have. Yet, his sisters are protected by law, regardless of parental wish. The use of an election here is because legislatures and courts are not doing their job to protect those rights equally for all citizens. The flaw is in the reason this method is necessary, not the method itself.

Of course, opponents of circumcision – who call themselves “intactivists” – are free to make their argument against a medical procedure they consider “male genital mutilation.” But what they should not be free to do is criminalize a religious ritual that medical authorities generally agree is not harmful.

It is harmful. It removes healthy, normal tissue and nerves. It leaves a wound that results in a scar. The only debate over whether circumcision is harmful is carried out by people who believe that subjective preferences are universal, and anyone who does not share one’s opinion is somehow misguided or uninformed. We don’t have to look for the examples of circumcision complications, including death, to understand the obvious truth that all surgery inflicts harm. Legally and medically.

As for Mr. Haynes’ implied rejection that male circumcision qualifies as genital mutilation, the World Health Organization defines female genital mutilation as follows (emphasis added): “Female genital mutilation (FGM) comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.” In other words, any surgical intervention less damaging than male circumcision, inflicted on females for the exact reasons we cite for male circumcision, would still qualify as genital mutilation. To avoid confusion, any reason for circumcising a healthy male child is non-medical. If we are to pretend that chasing potential benefits counts as a medical reason for surgery, then parents may impose any intervention they wish, unrestrained by society. We reject that, correctly, since children have rights. The only viable conclusion is that societal deference to non-therapeutic child circumcision is mistaken and should be corrected.

As a society we’re establishing that “one’s right to life, liberty, and property, to free speech, a free press, freedom of worship and assembly, and other fundamental rights may not be submitted to a vote,” unless one is a male minor. That’s what all of these individuals advocates, albeit ignorantly. They argue for a viewpoint where male children do not possess the same rights as everyone else in society, because society’s opinion is the correct norm to which male children must conform forever, if demanded by their parents. That is wrong. Each of these advocates – Dr. Mohammad A. Khalid, Dr. Aseem Shukla, and Charles C. Haynes – is wrong on non-therapeutic male circumcision.
Charles

Bad Public Health Policy By Irrelevant Anecdote

In an opinion column titled, “Circumcision Saved My Life,” Diane Cole writes that her late husband’s circumcision saved her from becoming infected with HIV after he became infected during a blood transfusion in the mid-1980s. Perhaps, but anecdotes make very bad policy. This is especially true when the anecdote doesn’t apply to the facts at hand:

It’s a personal story, but let it also serve as a public health rebuttal to the proposed ban on male circumcision that will be on the San Francisco ballot this November.

San Francisco’s ballot initiative would prohibit circumcision on all males under the age of 18. It would allow no religious exemptions, and it apparently gives no regard to the numerous studies demonstrating that male circumcision can substantially reduce—by more than 50%—the transmission of the HIV virus during sex.

The protection from HIV has been shown in Africa using voluntary, adult male circumcision. The San Francisco proposal would not prohibit voluntary, adult male circumcision. It’s ethically different from non-therapeutic male child circumcision because children cannot consent to having their healthy foreskins removed. Ms. Cole’s story is sad and unfortunate, but it is not a rebuttal to the proposal in San Francisco.

“Voluntary” Is Voluntary

From Tanzania:

Bukoba. The drive to circumcise about 9000 men living on the islands of Lake Victoria and surrounding environs in Kagera region has started in earnest, expecting to thwart the spread of HIV/Aids in the area, where prevalence of the disease is as high as 35 per cent.

As of January this year, about 1158 men of the target group aged between 10 and 50 years were circumcised, according to statistics provided by the International Centre for Aids care and Treatment Programmes (ICAP).

The target group of “men” includes 10-year-old children. This isn’t surprising, as the expressed idea of voluntary, adult male circumcision is always meant to signal a nonexistent commitment to ethics. It’s also rare that this blatant disregard for ethics is hidden. The disconnect is so strong that the presence of potential benefits is viewed as a guarantee that any non-voluntary recipient will acknowledge the gift upon proper reflection. This is a large factor in the blindness to the obvious ethical flaws of non-therapeutic child circumcision in the United States (and other Western countries).

What’s not usually quite so blatant is this level of open contradiction within a single article:

Among 1158 people circumcised towards the end of this year in the Lake Victoria islands, 317 were children aged between one and14 years, while those aged 15 to 25, the group thought to be most sexually active, were 551. Others who agreed to be circumcised included 260 men aged between 26 and 50 years.

More than 27% of the males “aged between 10 and 50 years” who were circumcised were children between one and fourteen years old. I’ve never met a 10-year-old man, but there can be signs of manhood. Perhaps the voluntary consent necessary to make non-therapeutic circumcision ethical is possible. The pretense that 1-year-old men exist and that these minors consent to surgical alteration is a disturbing, all-too-common trend in public health fanaticism.

When public health officials say voluntary, adult circumcision, they never mean voluntary or adult.

Compare and Contrast

Consider this first paragraph:

More men are turning up for Voluntary Medical Male Circumcision in Nyanza following a rapid campaign, latest study has shown.

Compare it to this first paragraph:

Consolata Nyansu, 11, is a girl in distress following pressure from her family to face the circumciser’s knife.

These two articles are from the same news¹ source, separated by a little more than two weeks. The narrative never changes. Males volunteer to undergo genital cutting. Females are forced to undergo genital cutting. Yet, when looking closer, this narrative predictably fails. (emphasis added)

“With last year’s [Rapid Results Initiative], we have now reached almost 230,450 men and boys with VMMC services,” [Nyanza PC Francis] Mutie said.

So it’s not all men volunteering. The article offers this explanation:

[Nyanza Provincial Director of Public Health Jackson] Kioko also said the initiative had also succeeded in reaching its target age group — men older than 15 — who can benefit most from male circumcision for HIV prevention. About 84 per cent of the clients were in this age group.

Fifteen is playing loose with the definition of man versus boy, but it may not be objectionable here since a 15-year-old is theoretically capable of giving consent free of outside pressure. However, the next paragraph provides insight into a possible explanation for the change in 2010:

During the first RRI study for [Voluntary Medical Male Circumcision] in 2009, which reached more than 36,000 men in 30 days, 47 per cent of clients were under 15.

That means, in 2009 under this allegedly voluntary male circumcision initiative, approximately 16,920 “men” were boys under 15-years-old. Perhaps some of them were 11-years-old (or younger), like Consolata Nyansu? Did they really volunteer?

I do not intend any trivialization of what is done to girls like Consolata Nyansu. My purpose here is to demonstrate that the narrative does not justify the illusion of disparity assumed between male and female genital cutting. The issues are the child’s lack of medical need and lack of consent. Any other reason is an excuse that should be dismissed.

This includes scenarios where facts are ignored to present what someone “knows”. The inclusion of this, from the second article, is admirable since it would likely be edited out of any Western article. (emphasis added):

Rabu Boke Yusuf, 50, from Ntimaru never underwent FGM because her resolute father stood by her.

“It is parents, especially women, who excite the desire to undergo the ‘cut’. A parent falsely tells her daughter that her age mates have been ‘cut’ to make them interested. Women are yet to believe their daughters can be married without being circumcised,” says Boke.

Any Western society discussion of FGM will include comments that it is men imposing it on women to control sexuality. The example here is not meant to suggest that men don’t impose FGM on their daughters or that’s it’s not done to control sexuality. I aim to demonstrate that facts are more complicated than that simple summary. Facts don’t care what we want to be true. Our own biases allow us to wrap this issue in points beyond protecting children from unnecessary genital cutting. We use that to pretend that gender is relevant to distinguishing between bad non-therapeutic genital cutting on a non-consenting person and “good” non-therapeutic genital cutting on a non-consenting person. That’s the implicit demand in the two articles because the first sweeps aside any distinction between man and boy and how that affects the voluntary aspect of voluntary male circumcision.

¹ This is from Kenya, but it is the default approach for most discussions of non-therapeutic genital cutting in the United States.

Concern for Individual Health

From last week’s headlines:

Researchers have documented yet another health benefit for circumcision, which can protect men against the AIDS virus, saying it can protect their wives and girlfriends from a virus that causes cervical cancer.

This doesn’t accurately qualify for the term yet another. It’s merely a sales tactic by an ignorant reporter. This potential benefit has been reported for decades.

Regardless, this should change nothing in anyone’s analysis about whether or not parents may legitimately force circumcision on their healthy sons. Their sons are not engaging in sexual activities, and will not for many years. When they do, they would still need t practice safe sex. (Their partners will still need to do the same.) The decision does not need to be made at the child’s birth.

There are several additional points to remember:

GlaxoSmithKline and Merck make vaccines against HPV but they are not available to most women in developing countries.

The ethics of these vaccines involve many of the same issues involved in male circumcision, but the key fact from this excerpt is that these vaccines are available in the United States. Combined with safe sex practices, there are alternatives. There is no reason to continue pushing infant male circumcision instead.

Also:

“We are not at all mandating that everyone should be circumcised, but we disagree that the evidence is ‘conflicting’ as the AAP says. We believe the public should be aware of the existing evidence and it should be a decision among parents that are informed of this evidence,” [Dr. Aaron] Tobian says.

The issue isn’t whether the evidence is conflicting. It’s hubris to assume we know the answers, as the constantly-changing nature of scientific findings shows. Still, if we assume that these findings are accurate and definitive, it doesn’t change the correct conclusion against non-therapeutic child circumcision. The boy is healthy, so he doesn’t need the surgery. He may not want it when he can comprehend the unavoidable negatives of the surgery. It is, therefore, unethical to impose it on him for some potential, possibly-never-to-be-realized benefit.

For final consideration:

“There’s no doubt that male circumcision provides a certain degree of protection against sexually transmitted diseases,” adds [Dr. Thomas] Quinn, “and male circumcision needs to be reevaluated by leading health authorities as to its true public health benefit, not just to men but to future female partners.”

Imagine the reaction if scientists suggested cutting female children to protect the health of adult males. That would correctly generate outrage. Accepting the sexism inherent in the opposite scenario, as embraced in articles like the two above, is no more justifiable.