Category: STD

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.

“May Help” Is Speculation, Not Science

This article in The New York Times covers the basic summary of the recent re-analysis that voluntary adult male circumcision in Africa can reduce the transmission of HPV to females. It has one inexcusable problem and an inference a thinking person should draw from it.

First, the problem:

Male circumcision, which has been shown to decrease a man’s risk of contracting the virus that causes AIDS, also appears to help protect his sexual partners against cervical cancer.
…

The study, led by researchers from Johns Hopkins University, did not last long enough to see how many women actually developed cancer; that can take years or decades.

HPV doesn’t appear in the article. Instead, voluntary adult male circumcision “appears” to help protect against cervical cancer. Yet, the reporter then states that the researchers didn’t actually study whether or not circumcision reduces the risk of cervical cancer because studying cancer can take years or decades. So why does the reporter write that circumcision protects against cervical cancer, rather than writing the actual suggestion that circumcision appears to reduce the risk of HPV transmission? HPV is not one virus, and not all strains cause cancer. This is irresponsible journalism based on the myth that circumcision is “good”.

The inference:

Cervical cancer was once a major killer in wealthy countries, but because of Pap smears it is now much rarer. In poor countries, it kills almost 250,000 women a year, according to the National Cancer Institute.

Papilloma vaccines like Gardasil and Cervarix provide much greater protection than circumcision does, but they are too expensive for most poor countries.

Cervical cancer is now much rarer in the Western nations because we have methods to detect it earlier. It is also less likely to kill in the future because now there are non-surgical vaccines that provide much greater protection than circumcision. So, the findings aren’t nearly as impressive for the readers of The New York Times because there are better detection and prevention methods. And the target audience for circumcision among the readers of The New York Times are parents of infants today. Those children will grow up in the same world where better detection and prevention methods exist, and will likely improve further by the time they’re at risk for sexual transmission of HPV.

Medically and ethically, this finding is irrelevant to the question of whether or not parents should consider forcing circumcision on their children.

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.