Category: STD

Infant Male Circumcision and Current Human Rights Disparities

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

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

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

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

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

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

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

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

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

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

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

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

… and provides significant protection against human papillomavirus infection. …

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

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

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

The Marketing Changes Again

Hospital Male Circumcision has been sold with evolving euphemisms in an attempt to hide the ethical flaw in the associated public health policies. First, it was Voluntary Medical Male Circumcision, which never meant voluntary or even medical. The only requirement was a penis with a foreskin. Then it changed to Medical Male Circumcision. That involved 50% less pretense, while retaining 100% of the ethical omission. Now, it’s changed again:

Health facilities across the country have run out of supplies for Safe Male Circumcision kits, an HIV expert has said.

It’s better that they dropped medical, but replacing it with safe is little better. First, males will suffer complications beyond the guaranteed loss of the foreskin. Most of them will be minor. Some of them will be significant. Safe will be false.

It’s also possible the word’s meaning will be misconstrued.

The medical practice is intended to prevent HIV infection but it is not 100% safe, medical experts claim.

According to World Health Organisation and United Nations AIDS (UNAIDS) trials in Uganda, South Africa and Kenya have shown that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%.

I can’t fathom a scenario in which the public health officials intended safe to describe HIV after circumcision. Yet, that’s what this reporter took from it. That does not bode well. That’s a danger of propaganda. It’s inexcusable because there are lives at stake.

The premise of the article is worth addressing, too. They’ve run out of supplies. The article implies that they’re not circumcising while they lack supplies. That’s the right answer, of course, so I hope that’s what is happening. But I’m also concerned by the description of the kits as containing “reusable and disposable supplies”. Are they adhering to that distinction? And are the reusable supplies being sterilized properly?

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.

That Word Doesn’t Mean What Secretary Clinton Thinks It Means

October 1, 2015 update: I changed the word “condemnable” to “commendable” to reflect the intended meaning of a sentence. Additionally, the link to Secretary Clinton’s comments is now here.

The United States government encourages and funds circumcisions. It shouldn’t, of course, if we’re to adhere to the basic principles of human rights. (We don’t on this.) But it shouldn’t be promoted with lies. U.S. Secretary of State Hillary Clinton spoke yesterday at the 2012 International AIDS Conference. (emphasis added)

As of last fall, every agency in the United States Government involved in this effort is working together to get us on that path to an AIDS-free generation. We’re focusing on what we call combination prevention. Our strategy includes condoms, counseling and testing, and places special emphasis on three other interventions: treatment as prevention, voluntary medical [sic] male circumcision, and stopping the transmission of HIV from mothers to children.

Any familiarity with this subject provides a spoiler alert on what voluntary really means. Sure enough, shortly after that paragraph:

On male circumcision, we’ve supported more than 400,000 procedures since last December alone. And I’m pleased to announce that PEPFAR will provide an additional $40 million to support South Africa’s plans to provide voluntary [sic] medical [sic] circumcisions for almost half a million boys and men in the coming year. (Applause.) You know and we want the world to know that this procedure reduces the risk of female-to-male transmission by more than 60 percent and for the rest of the man’s life, so the impact can be phenomenal.

In Kenya and Tanzania, mothers asked for circumcision campaigns during school vacations so their teenage sons could participate. …

Voluntary circumcision requires the consent of the circumcised. Consent from anyone else for non-therapeutic circumcision is unethical.

And, no, it isn’t “medical” circumcision. It’s medicalized circumcision, which merely indicates that it’s performed in a modern, sterile operating theater. That is commendable in its limited focus, but it is not enough to render the non-therapeutic surgery ethical. Consent is also necessary. The perceived benefit of a reduced risk of female-to-male HIV transmission is a speculative pursuit and may not be necessary or desired by the individual.

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.

Flawed Circumcision Defense: Yair Rosenberg

In what appears to be an attempt at a GOTCHA! in response to the German court ruling, Yair Rosenberg offers a weak effort touting the potential benefits of non-therapeutic circumcision. He opens:

“Male circumcision is a highly significant, lifetime intervention. It is the gift that keeps on giving. It makes sense to put extraordinary resources into it.”

Who would you guess recently offered this paean to foreskin fleecing? A rabbi? An imam? Nope. Try U.S. AIDS coordinator Eric Goosby at a health convention last month for top officials from 80 countries.

This smacks down the logic of a German regional court that has banned religious circumcision, calling the practice a “serious and irreversible interference in the integrity of the human body.” …

Mr. Goosby’s statement, used as an appeal to authority, does not smack down the logic of the German court. Circumcision can impart potential benefits when it is imposed on a healthy child, while meeting the court’s statement that it is a “serious and irreversible interference in the integrity of the human body”. The imposition on a healthy child makes it unethical. There is no need for an allegedly-required belief that the science isn’t real. Mr. Rosenberg’s argument focuses on ends without a complete consideration of the means.

He next offers the inevitable appeal to a reduced risk of HIV. As almost every advocate does, he omits the relevant caveats. The risk reduction is in female-to-male HIV transmission in high-risk populations. Neither describes the HIV epidemic in any Western nation, including Germany. Even if it did, the studies involved voluntary, adult circumcision, not infant circumcision. That’s the ethical question. Infants can’t consent. They also won’t be having sex any time soon. There is no immediate need to force non-therapeutic circumcision on them for this potential benefit.

His next tactic is revealing. He quotes a story on the HIV studies. The story quoted unnamed federal health officials who declared that the studies were halted early because the findings made it “unethical to continue without offering circumcision to all 8,000 men in the trials”. Okay, fine, they offered circumcision to the control group. Mr. Rosenberg states:

Unethical not to circumcise the men.

No. Researchers deemed it unethical to not offer circumcision to the control group. That’s a huge difference. The control group men retained the right to reject circumcision. One might say this distinction is “highly significant”. Mr. Rosenberg seems to have missed the entire ethical issue. The issue is the imposition of circumcision, not whether or not someone could (or should) conclude that circumcision for himself is awesome because of various possible benefits.

He returns to an appeal to authority:

… The American Academy of Pediatrics is soon expected to come out with a new policy pushing circumcision, reversing its prior stance.

I’m not a fan of the “no medical association recommends it” argument because it’s an appeal to authority and because it could change. But the same problem applies to using a medical association’s support. In the latter case, it’s an evaluation without regard for what the individual needs or wants. It’s untethered from rights and reason.

He continues (emphasis added):

Given this impressive scientific consensus as to the medical dividends of male circumcision, the German court’s judgment—which permits circumcision for “medical reasons”—is a confused and ignorant muddle. Some have rightly criticized it as an assault on millennia of Jewish tradition and practice (not to mention Islam), something one would have thought a German court would be sensitive enough to avoid. But the ruling itself, as the research above amply demonstrates, is logically incoherent and factually wrong for a simple reason: All circumcisions are medically beneficial. Whether or not the procedure stems from religious motivations, it will have measurable health benefits. So by the court’s own reasoning, all religious circumcisions ought to be permissible as long as the parents also want the medical dividends—which effectively means that circumcision has not been banned at all. Of course, it is very unlikely that this is what the court intended and much more likely that it was entirely unaware of the scientific consensus surrounding circumcision’s advantages.

First, it seems clear that the court meant “medical reasons” to mean “medically necessary”. In saying that the court’s reasoning renders non-therapeutic circumcision valid based on merely mouthing the words “medical benefits”, he is echoing the silly argument many push that pretends prophylactic circumcision is “medical” circumcision. It is not. Non-therapeutic child circumcision involves proxy consent, not consent, so the only valid medical reason is need. As Mr. Rosenberg acknowledges, this interpretation is not likely the court’s intent. Assuming that this means the court was unaware of the science is too convenient. It begs the question. “They ruled circumcision is harm, so obviously they didn’t consider the benefits. If they had, they’d know that all circumcisions are medically beneficial and rule accordingly.”

Within either analysis, his conclusion is still wrong. The italicized bit is Mr. Rosenberg’s personal evaluation. It is his subjective conclusion based on his preferences. (He indirectly admits this later.) It is not an objective fact. The only objective fact is that circumcision inflicts some guaranteed level of harm. There is also the possibility of unexpected harm reflected in further complications, which contradicts his “all circumcisions” insistence.

Not everyone will value the potential benefits the way he does. I don’t. The HIV benefit he cites, the one that barely applies to Western societies, is effectively moot if a male simply wears a condom when he has sex. The same ease of prevention applies to HPV, for which there is also a vaccine approved for females and males already exists. And so on. The remaining benefits are generally achievable through less invasive preventions and/or treatments. The most invasive surgical option on children as a prophylactic measure can’t be justified ethically.

Or to put it in extreme terms, is circumcision medically beneficial to the boys who will lose more than their foreskin? What about the boys who die? Is circumcision medically beneficial to them? All circumcisions are medically beneficial, right?

He also misstates the goal of activists:

But that scientific consensus reveals more than just the follies of this German court; it also exposes the deeply problematic aims of American advocacy groups which seek to outlaw circumcision for the entire United States. …

The goal is to prohibit non-therapeutic circumcision on non-consenting individuals. It is not to outlaw circumcision, full stop. That’s his meaning, but precision matters here, just as it does when discussing the reduced risk of female-to-male HIV transmission in high-risk populations.

After trotting out the tired “why do you hate the poor?” argument, he writes:

… It’s one thing to abstain from a potentially medically beneficial procedure due to personal convictions; it’s quite another to enforce those convictions coercively on others.

Children who have circumcision forced on them do not get to abstain due to personal convictions. They had someone else’s convictions enforced coercively on them. If Mr. Rosenberg understands the ethical issues involved, he hasn’t shown it yet.

Ultimately, those who seek to ban circumcision as the essential equivalent of child abuse—from this German court to activists who recently attempted to bar the practice in San Francisco—are doing so in the face of tremendous scientific evidence to the contrary. Their claims are at odds with countless studies, not to mention global health policy. The burden of proof, then, is upon these activists to defend their disregard for this science, not on the majority of Americans who choose to circumcise their children and take advantage of its documented benefits.

This isn’t how the burden of proof works, since proponents of non-therapeutic circumcision on non-consenting children are the people advocating intervention contrary to the normal, healthy body. It warrants an answer, regardless. I do not disregard this science. I accept it all. I just don’t foolishly pretend that the possibility of a benefit permits me to disregard ethics or the vast amount of science beyond claimed benefits from non-therapeutic circumcision. The normal, healthy foreskin is science. The ability of soap and water to cleanse the penis, foreskin included, is science. Condoms are science. The power of antibiotics to treat infections is science. If we are to take Mr. Rosenberg’s narrow reasoning as a valid replacement for ethics, any surgical intervention on a child becomes acceptable if some rationale about possible benefits can be found. There is no limiting principle that respects rights. It’s based on one’s preference for circumcision about one’s child, without regard for what the child needs or might (not) want.

He concludes¹ with this:

After all, individuals are free to discount scientific evidence on the basis of value considerations, even dubious ones, and base their life decisions upon that calculus. But such subjective notions should never form the basis for coercive state policy any more than, well, religion.

Individuals are free to discount scientific evidence on the basis of value considerations. I do. I accept the benefits, but I value other aspects of the issue more. Ethics, bodily integrity, and normal body parts all matter more to me than the possible benefits. Whether that’s dubious or not for me is not for anyone else to decide. Yet I don’t have any freedom on this. My parents had me circumcised. They made my decision on their subjective calculus. It was the basis of their coercive parental policy. If the issue is force, and it is, the only illegitimate force exercised here is circumcising healthy children. Prohibition is the defensible position.

If we want to discuss whether prohibition is the best approach to solving the violation of non-therapeutic circumcision on non-consenting individuals, that’s a discussion worth having. Cultural change is likely to be far more effective. Society, in general, and religions, specifically, have changed. There’s no reason to believe it can’t happen here. It should. It will. In the meantime, though, children are having their decision made with force. Agitating for change through multiple avenues, including the law, is reasonable.

¹ He actually concludes with “Your move, Foreskin Man.” That’s not an argument. I’ve written what I need to say on that topic.

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.

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.

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.