Category: STD

The Lie Feeds Itself -PrePex and Unethical Circumcision

Note: I updated the title after posting this entry.

I wrote this in December 2011:

… 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.

And this, in February 2012, in a footnote:

This is where I’ll invoke the articles on the PrePex as an example. My objection to the recent pieces about it centers on the poor journalism rather than the device. I expect the device will eventually be tweaked to allow for infant circumcision at some point. That would be wrong. For now it’s a device for voluntary, adult circumcision. I have no objection to that. The claimed risks involved with the device are low. The claim that adult circumcision is more dangerous than infant circumcision doesn’t appear to hold up, generally, regardless of the method. This claim is a framing device of dubious quality rather than a fact to be [sic] negate ethics.

I expect the device will eventually be tweaked to allow for infant circumcision at some point. And four years later, this press release, from last month (emphasis in original, footnote added):

The World Health Organization (WHO) expanded the Intended Use of the currently-prequalified PrePex device to include adolescents aged 13 years, and above. Effective immediately, the PrePex device, manufactured by Circ MedTech, can be offered for adult and adolescent males in the 14 priority countries in Southern and Eastern Africa. PrePex was the first male circumcision device to receive WHO Prequalification on 31 May 2013.

Circ MedTech’s CEO, Eddy Horowitz said: “The expanded use of PrePex for younger ages will sustain Voluntary [sic] Medical Male Circumcision (VMMC) programs in the 14 Sub-Saharan Africa priority countries and will serve the new UNAIDS Sustainable Development Goal (SDG) of an additional 27 Million male circumcisions by the year 2020.”

Circ MedTech Ltd. is in the advanced stages of adapting its PrePex technology for use with infants¹ and children, thus offering safe male circumcision services to all ages, worldwide.

At least they dropped their lie about “voluntary” in the last paragraph. But they still include it in their FAQs.

Why is it called “Voluntary Medical Male Circumcision?”

“Voluntary Medical Male Circumcision” is a term used by the global health community to emphasize that circumcision is a personal choice.

“Voluntary Medical Male Circumcision” is a term used by the global health community for propaganda. The global health community (i.e. public health officials) does not care, has not cared, and apparently will not care, about “voluntary” (or even “medical”, since this surgery is “medicalized”, not medical, circumcision). The expansion of PrePex to children who can’t consent demonstrates this. Volunteer and volunteered are not synonyms here. The global health community legitimizes whoever’s choice results in a statistic, the removal of another normal, intact male’s foreskin. Remember, the measure of success in these campaigns is “male circumcisions”, not something relating² to HIV infection rates, the alleged, stated aim of “Voluntary” “Medical” Male Circumcision.

If those involved with PrePex cared about ethics, this expansion of the product line wouldn’t occur. But here we are with the above evidence and the questions raised by more from their FAQs, such as:

What is Voluntary Medical Male Circumcision? (click to read answer)

In 2007, the World Health Organization (WHO) and UNAIDS announced recommendations,based on extensive studies, to scale up Voluntary Medical Male Circumcision (VMMC) to men in areas of high risk for heterosexual HIV transmission. The studies showed that men with a circumcised penis are approximately 70 percent less likely to contract HIV from heterosexual intercourse than men with an uncircumcised penis–in addition to other health and hygiene benefits.

This finding, replicated in rigorous, repeated studies across several countries, has led doctors and public health professionals to recommend that men in high-risk areas have access to VMMC.

Imagine a person who doesn’t know what Voluntary Medical Male Circumcision is. Now imagine that person reading the answer PrePex gave to his question, “What is Voluntary Medical Male Circumcision?”. Does he now know what Voluntary Medical Male Circumcision is? Circ MedTech already showed they don’t know what “voluntary” or “medical” mean. They should be able to pretend better than the word salad they provide.

Let me try:

What is Voluntary Medical Male Circumcision?

Male circumcision is the permanent removal of the foreskin (i.e. male prepuce), the fold of skin covering the penis. This may also involve removal of the frenulum.

The procedure is voluntary and only offered to males able and willing to consent. This consent is achieved by providing a detailed explanation of the benefits, costs, and risks associated with male circumcision. The medical provider will emphasize what is guaranteed versus what is possible for the benefits, costs, and risks. With this knowledge, the individual may decide for himself if he wishes to proceed and be circumcised or not. The procedure is carried out only with his affirmative consent.

Circumcision is best carried out in a medical setting. It is recommended that, if the individual consents, this be performed in a sterile setting with trained professionals to minimize risks and negative outcomes. The risk of complications cannot be completely eliminated.

They can’t say that because it’s true and rules out the option to circumcise healthy children. Instead, they ramble about the perceived benefits. One should assign a level of trust corresponding to how forthcoming they are on the risks, so not much.

The lesson remains the same. When public health officials (i.e. the global health community) promotes “voluntary” (“adult”) male circumcision, they never mean “voluntary” (or “adult”).

¹ WHO TECHNICAL ADVISORY GROUP ON INNOVATIONS IN MALE CIRCUMCISION: “Providers must be trained to recognize when an adolescent is not eligible for the PrePexTM device due to inability to retract the foreskin or discomfort while attempting to do so, or when there are adhesions or phimosis. …” The inability to retract the foreskin is normal at birth because it adheres to the rest of the penis.

² Even where it is something related to HIV, do we have enough to determine causation rather than correlation? Possibly. I don’t know. And to repeat, I don’t care if adults choose circumcision for themselves. What each person does with his body is up to him. Nor do I state unequivocally that all potential benefits are illegitimate. The argument for imposing circumcision on a healthy child in pursuit of those potential benefits is, though. Always. The removal of his foreskin is a price the individual may not wish to pay.

The One Concept You Need to Know about Routine Infant Circumcision

Here’s a frustrating analysis of circumcision, 5 Ways Circumcision Affects the Rest of Your Life. It’s throwaway click-bait at its core. I clicked, they won. There’s still something interesting within the list:

Most guys have no choice in whether they have a foreskin or not. Nearly 60 percent of male newborns in the U.S. get circumcised at birth, according to the Centers for Disease Control and Prevention. But your parents’ decision about that tiny bit of skin has far- and wide-ranging implications. …

The list deserves credit for not being entirely ridiculous in its approach. It provides the ethical map from its first words. The first item is circumcised men “last longer”. That isn’t presented as an unquestioned benefit. And the second item is the possibility of sexual difficulties for female partners from male circumcision. So, yay. But then the third item:

Before you get bitter[¹] about the female orgasm thing, thank Mom and Dad for this: Circumcised men are less likely to get penile and prostate cancer[²], research finds. …

It’s reasonable to get bitter about the “female orgasm thing.” It’s even more reasonable to get bitter about the “last longer” thing. The first five words of the author’s essay, “most guys have no choice,” demonstrate that mom and dad deserve no thanks or applause for taking that choice away. I accept that some men “thank mom and dad” for “last longer”. That post hoc rationalization can’t change the ethics. Bad things happen in every circumcision. Other bad things can also happen from circumcision. Until the child expresses his affirmative consent to non-therapeutic circumcision, mom and dad need to keep their preferences to their own body. His body isn’t their choice.

¹ Whether bitterness (i.e. anger) is productive as a driving motivation is a separate concern.

² Again with this.

I Guessed What Phase Two Involves

Oh, what could this transition be?

The National Voluntary Medical Male Circumcision taskforce has rolled out the second phase of circumcision on regions with a high burden of HIV this time targeting over 1 million men.

The chairman of the Inter County Taskforce on Male Circumcision Dr Ojwang Lusi said the program is transitioning to the second phase of implementation that will run to July 2019.

We all guessed what this means.

The second phase will lower the circumcision age of boys to between 10-14 years.

I assume there’s a Phase Three – or an undocumented aspect of Phase Two – involving infant “men”. Predictably, it’s obvious why.

Lusi further noted that some challenges emerged in the first phase that they will strive to address as the second phase.

He said most of the men above 25 years declined to go for the exercise with limited number of women getting involved in the exercise with their husbands.

Men won’t volunteer, so child men get “volunteered”. As always with those who are unethical, because outcome matters instead of consent.

Joint Government Effort to Eradicate Consent

As always:

The Ministry Of Information and Communication Technology in partnership with the Ministry of Health and the centre for Disease Control in America are collaborating on a National Strategic framework known as the Voluntary Medical Male programme which is a joint government effort to eradicate the long struggle of HIV/AIDS infections.

HIV/AIDS has always been the countries top priority with the health ministry being pressured to reach their ambitious 2030 vision to bring HIV/AIDS infections to zero in the country.”The Centre for Disease Control and the Ministry of health have had three randomised controlled trial runs of the voluntary medical male circumcision programme prior to it’s launch in 2009. With the success of the programme around 20,000 sexual active males have been circumcised to date thus raising 80% awareness to men to encourage more males in considering medical circumcision,”said programme specialist Mr Dan Rutz of CDC.

Somehow success is measure in “males circumcised” without giving any statistics on HIV rates¹. So it’s easy to predict what “encouraging more males to consider ‘medical’² circumcision” means:

“Medical male circumcision has been found to be cost effective, as well as all procedures are free at clinics it has been known that healthy employers increases work productivity within any work environment which leads to a steady healthy work environment that enables the economy to grow,” added Rutz.All males that have not been circumcised are encouraged to do so as procedures can be performed at all local regional clinics in the country as government want to achieve it’s target to circumcise 330,000 men between 15 to 49 years by the end of 2016.The Ministry would also like to implement a national policy programme known as an Early Infant Circumcision strategy in the near future that will enable newly born babies to be circumcised.

“Enable”. Newborn males won’t get to consider or volunteer. They will be considered and volunteered, their needs, preferences, and preventative options deemed irrelevant. They are only pieces by which public health officials measure their own professional success.

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

¹ A drop in HIV infections would be welcome. It cannot justify violating ethical obligations to protect the rights of non-consenting individuals.

² Circumcision in this context is medicalized, not medical. Merely performing non-therapeutic genital cutting in a sterile operating environment does not make it necessary. This is also not a defensible term to justify performing non-therapeutic genital cutting on a person who does not offer explicit consent.

President’s Endless Plan for Avoiding Rights

PEPFAR held an event today, described as:

Join global health experts in PEPFAR’s sixth VMMC Webinar to consider the pros and cons of offering early infant male circumcision (EIMC) as part of routine Maternal, Newborn and Child Health (MNCH) care.

The title of the event was, “Scaling Up Routine Early Infant Male Circumcision within Maternal, Newborn and Child Health”. I wonder what the outcome of considering the pros and cons will be.

It’s also worth noting how circumcising infants has been separated as EIMC from “voluntary” male “medical” circumcision (VMMC). Is it progress if they’ve stopped pretending that infant circumcision is voluntary? Not really, I think, since no one involved cared anyway and dropping it means they’re comfortable with making it clear they don’t care.

Who won here? – Part 2

In my recent post, I commented on the following video:

I provided an answer to the doctor’s question, “If there was a vaccine for HIV that reduced the rate by 50%, would you be okay or would you be protesting?” In discussing the post with a friend, he offered an excellent follow-up to this. The doctor should answer this question: If there was a vaccine for HIV that reduced the rate by 50%, would you be okay or would you continue advocating for circumcision?

Who won here?

This video is interesting to me:

The doctor’s evidence-free accusation at the end, “anti-Semitic like you”, is both disgusting and interesting. I side with Brother K’s response and outrage on that charge. The problem is that no one in that video was talking to anyone else. Everyone was talking at each other. I assume all four people walked away thinking they won the interaction. Instead, I want the video where the doctor’s question gets a response rather than an information dump. Show him how his question – and by extension, his view of circumcision – is broken.

His question is excellent: “If there was a vaccine for HIV that reduced the rate by 50%, would you be okay or would you be protesting?” It provides insight into what concerns the doctor professionally. It provides a chance to discuss more about HIV than just this isolated 50% claim. It provides a direct way to distinguish the ethics of vaccination and removing body parts. It provides the doctor an opportunity to experience someone who has thought about this more than just “don’t hurt the babies”.

Non-therapeutic child circumcision is indefensible. The burden of proof should be on those who want to circumcise. They propose intervention. They haven’t proven their case. They can’t prove it because it’s flawed. But society puts the burden of proof on those who challenge tradition, not those who wish to intervene on the healthy body of a non-consenting child. It’s wrong, yes, but we have to work with society tilting at this windmill. Do we want to change society or do we merely want society to know we’re better? My preference is for the former, and especially so when seeing how little the doctor in the video agreed to the latter.

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It’s a valid expectation, so my answer to the doctor’s question is this:

Yes, I would be okay with it (qualified by verification of both efficacy and safety of the vaccine within some reasonable bounds). Circumcision isn’t a vaccine. Vaccine’s work with the body’s immune system to trigger a response that then protects the individual from infection. Circumcision removes skin. It operates on the theory of “less skin, fewer entryways”. This is relevant, too, since the mechanism for the claimed risk reduction from circumcision is unclear. Perhaps it’s a confounding factor not yet understood and/or researched? There’s also the scientific fact that condoms work better and do not involve the violation of human rights. And, what about the possibility that removing bits of female genitals could reduce risk? Are we ethically bound to allow that, too, or does it reveal the ethical question we don’t wish to consider? We know it’s unethical to investigate, because the answer doesn’t matter. Our societal fear is convenient, not justified, when it comes to HIV and circumcision.

When all you have is a hammer

I’ve written about the blog The Case Against Intactivism before. I don’t expect much when a rare new post comes through RSS from paper0airplane. There are valid criticisms to be made about the behavior of some activists. To that extent, I don’t mind paper0airplane approach. I avoid engaging in those behaviors because they’re flawed and unhelpful. And I’ve criticized bad behavior in the past. I have no concerns about my credibility on this, or the credibility of many others I interact with, so paper0airplane’s posts aren’t about me. That’s why their general focus is frustrating¹.

So it is again with the latest post, AIDS workers baby rapists, which highlights examples of idiots celebrating the deaths of prominent AIDS researchers on Malaysia Airlines Flight 17 because the researchers maybe had connections to circumcision. I don’t know what else to say about those intactivists beyond this: any individual engaging in this behavior is an untrustworthy ass and no ally of mine. Personally, I’m for individual rights. That includes the right to not have one’s genitals altered for non-therapeutic reasons without one’s consent. It also includes the right to not get blown out of the sky by murderers. Obviously. This isn’t complicated for most activists. But that doesn’t sell a canned argument.

It’s also clear how short-sighted these idiots are. I have no idea which portion of those who died were involved in research promoting circumcision for HIV risk reduction. All or none, it doesn’t matter. Their deaths are bad for the push for bodily integrity over circumcision without consent because some of the smartest minds searching for an end to HIV are now dead. Even if every one of them pushed circumcision, their absence means fewer knowledgeable people looking for a cure. I’d guess that means a push for circumcision is more likely, or at least likely to continue longer than if the researchers were still here working.

But, again, regardless, celebrating their deaths is ugly, garbage behavior. It’s wrong. I do not support it.

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The point I still take from paper0airplane’s overall approach is that the good intactivists should call themselves something else because the bad intactivists are ruining the term. Well, sure, if your gig is talking about any activists as if they’re all guilty of what the idiots among them do, you’d suggest this change. A flaw in that rests with paper0airplane. If I call myself an intactivist and don’t engage in awful behavior, why am I the one who should abandon² the label? The label is a decent, if goofy, expression of what this activism wants. I don’t call myself an intactivist precisely because it’s so easy for others to smear or to lazily blame me for the terrible tactics of others. But whatever I call myself, it isn’t my responsibility to relabel myself because paper0airplane criticizes too broadly.

¹ We can all play this silly, unfair game. But I’m not willing to suggest that everyone who supports non-therapeutic child circumcision must own Vernon Quaintance. That isn’t a reasonable demand.

² It’s reasonable to abandon it because enough people associate it with the actions of a few. The cause and effect issue there would be an interesting discussion.

The AAP Discounts Its Patients’ Right to Physical Integrity

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

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

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

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

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

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

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

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

The AAP continues its challenge:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Their conclusion:

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

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

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