Category: “Voluntary”

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.

Inquiry Is Better than Insinuation

Rabbi Gary Creditor wrote an essay in the Richmond Times-Dispatch on the subject of circumcision, laws, and anti-Semitism. The title assigned is “Circumcision ban is veiled anti-Semitism.” The premise is absurd because it accepts no nuance into the discussion. It’s possible (and common) to oppose non-therapeutic child circumcision and anti-Semitism. The former can be expressed in clear principle without the latter. If Rabbi Creditor will make an effort to look, he will find examples.

Instead, this, after significant buildup:

Throughout history, those who sought to destroy the Jewish people always forbade brit milah, usually upon penalty of death. They thought that if they could eradicate the sign of the covenant, they could eliminate the covenantal people. They failed.

To the extent that I can (i.e. intellectually), I understand his concern. But this is not that. There is no effort to destroy Judaism or Jewish people. Any male may consent to circumcision when he is able. The proposed law would’ve set the age he could consent at 18, but I do not believe that is required. At whatever age he could consent, that would be acceptable. The focus is consent.

The proposed law would’ve established criminal penalties. That makes sense given that the fact involved is that non-therapeutic circumcision is (well-intentioned) battery, which violates the rights of the child. We criminalize female genital cutting on minors that causes less damage. There is nothing abhorrent about the proposed penalties. They would’ve very rarely, if ever, been enforced. That’s politics. But to connect a proposed year of imprisonment with capital punishment is inexcusably unfair.

That’s Rabbi Creditor’s premise. He exposes the flaw in his reasoning that demonstrates the principle of human rights and bodily integrity with his next paragraph (emphasis added):

That is the issue that reverberates these days in San Francisco with the attempt through legislation to ban all circumcision. It is a thinly veiled attack upon Judaism and the Jewish people. Anyone who objects to this ritual has the democratic right not to participate in it. Yet as parents with a religious persuasion, we make decisions on behalf of our children. One of those is the perpetuation of the faith. This is how we do it. This attack is not new — just its method. It violates core American principles.

I had a right not to participate in circumcision. I would exercise that right if I still had my choice. My parents (and the doctor) violated my right and my body when they circumcised me without medical need. Every human, male or female, possesses that basic right. Rabbi Creditor is mistaken. Society incorrectly fails to protect that right for male children, which violates core American principles. The core American principle is individual liberty, not collective “liberty” to permanently impose one’s beliefs on the physical body of another.

Flawed Circumcision Defense: LZ Granderson

The editorial I analyze in this post is several weeks old now, but it’s been referenced elsewhere a few times. It’s worth a response.

LZ Granderson wrote an editorial at CNN on the proposal in San Francisco to prohibit non-therapeutic male child circumcision. It’s an embarrassing piece, largely because Mr. Granderson never considers the healthy child as an individual who might not want to be circumcised.

Once he gets going:

Besides the measure having no provision for religious practices — thereby making it unconstitutional — …

This is armchair lawyering, and easily refuted. There are the merits of the First Amendment and parental rights, which are summarized quite well in these two posts at The Volokh Conspiracy from last week. The religious freedom to act on another is a lot more complicated than simply claiming a religious requirement. There are competing rights involved, including a right to be free from unnecessary harm that is not yet adequately (or equally) protected. Mr. Granderson’s dismissal is flawed. It doesn’t disqualify his opinion, but it suggests the level of research he has (not) performed on this topic.

We chuckle, but from interracial marriage to masturbation, politicians have been trying to tell us what to do with our genitalia for centuries. …

Here, parents are telling their sons what to do with their genitalia. If the male does not want his genitals altered, his genitals are still altered. Since his body has been violated, what difference is it to him that his parents did it than if his government had ordered it? The proposed government involvement leaves that choice to individuals rather than dictates how he must be, which is what parents have been doing for more than a century in the U.S. Proposals like this that protect individual rights possess the stronger liberty position.

I get the science behind not having the procedure done: There are nerve endings that are being severed during the procedure, and it is normally not medically required. But generally speaking it has not been proven to be medically harmful either, though there have been rare occasions of infection and excessive bleeding requiring stitches.

Surgery is harmful. How can Mr. Granderson acknowledge that in sentence one and then deny it in sentence two? In the space between writing those two sentences, did severing nerve endings become not harmful? It’s more frustrating because his denial includes examples of medical harm. Other, more severe, outcomes are possible, too, including death. Mr. Granderson seems determined to believe what he wants to be true, regardless of facts.

Besides being an important aspect of some religions, circumcisions improve hygiene, …

Access to proper hygiene facilities is not a modern American problem in significant numbers. The same hygiene that females use to maintain their bodies works for males. To think that surgery is justified is simply begging one’s own question.

… which is effective in limiting urinary tract infections and the transference of STDs. …

The same treatments we use for UTIs in females work for males. For STDs condoms work better. Not all males engage in unsafe sex, so the potential benefit is useless for them. It is unethical to impose it because it may not be desired.

…And speaking of sex, having a circumcised penis saves the young man of the potential embarrassment of having a new partner look at his nude body and say “What in the hell is wrong with your… penis.”

Or something like that.

Maybe.

A recent study conducted by a Centers for Disease Control and Prevention researcher suggests the number of circumcisions performed dropped from 56% in 2006 to 33% in 2009. So chances are you or someone you know is uncircumcised, a fact that is really none of the business of complete strangers — government officials and busy-body voters alike. Why someone would sign a petition making it their business is beyond me.

This is just ridiculous. If a man reveals his normal nude body to a new sexual partner and the response he gets is “What in the hell is wrong with your… penis?”, I hope his parents will have taught him enough self-respect to treat his new partner as the person with the (hopefully correctable) defect. Would we accept that thought process if we started surgically altering girls so that they wouldn’t be shamed by their eventual sexual partners?

I could see the government getting involved in the decisions parents make about their children if there was evidence that circumcisions were a life-threatening practice — like failure to use car seats for young children. …

The standard is not whether the action is “life-threatening” or not. A punch to the face isn’t life-threatening, but it’s still wrong. Genital cutting on healthy female minors is illegal (and wrong), even where the damage is equally or less harmful than male genital cutting, which is to say, not life-threatening. (Typically.) This is once again question-begging.

Of course, some boys do die from circumcision. Circumcision is not usually life-threatening, but the risk of death exists every time it’s performed, which is why we generally avoid inflicting surgery on healthy people. Especially without their consent.

… I could see if the proposed ban was addressing a patriarchal practice such as female genital mutilation.

Male circumcision is a patriarchal practice. Aren’t many boys circumcised by their parents, at the father’s insistence that the child’s genitals match his genitals? Some doctors advise undecided parents to make the decision based on the father’s penis. Is that the rule of the male? Does it subordinate children? Mr. Granderson’s view here seems to be the mistaken belief that there is no harm if a practice is being imposed by someone onto someone else of the same gender. Do I need to link to examples of women imposing FGM on their daughters to demonstrate the fallacy of relying on this faulty standard?

This is about choice and preference and opinion and I am really tired of being subjected to ridiculous laws instituted by religious conservatives pandering to a bunch of crazy people or by meddling liberals who have nothing better to do.

This is about choice and preference and opinion? In what way? The child being circumcised does not choose. No one cares about his preference. No one waits to hear his opinion. The child is subjected to the choice, preference, and opinion of his parents. Permanently.

Seriously, if municipalities in San Francisco or Santa Monica honestly believe parents can’t be trusted to decide what’s best for their newborn’s foreskin, why on earth would they let them leave the hospital with the rest of him? It just doesn’t make sense.

California law already believes that parents can’t be trusted to decide what’s best for their newborn’s foreskin, but on the discriminatory view that only the female prepuce should be untouched without need or consent of the patient.

No wonder these anti-circumcision organizers have their sights on the rest of the country. We’re a bunch of nosy busy bodies who believe in an abbreviated version of freedom where we’re free to publicly debate what someone else should do with their private parts or the private parts of their newborn.

The status quo is the society with an abridged version of individual freedom. Again, the law in California (and most other places) already ended the public debate on what someone may do with the private parts of their daughters. Does that restrict parental “rights”? This debate is about fixing the status quo into a legitimate version of freedom where every individual, male or female, gets to decide which unnecessary genital surgeries they undergo or reject.

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To address a point Mr. Granderson raises, the issue of the “Foreskin Man” comic book series is relevant to the discussion. It is not the end of the discussion, as some are suggesting. That the series is embarrassing, and that issue two uses anti-Semitic imagery, is undeniable. The comic book is disgusting and has no place in the discussion by anyone advocating against non-therapeutic male child circumcision. It is a shameful mark on its creators.

That said, I hope it’s abundantly clear that only a minority of people opposed to non-therapeutic male child circumcision accept this type of filth. As the Jewish Circumcision Resource Center states, “there is no organization that controls, or could control, what individuals who oppose circumcision may say or do.” The first issue of “Foreskin Man” is probably unhelpful, but issue two is unacceptable. But it’s not reflective of the principles involved or the majority of those who support and advocate those principles. I have commented elsewhere on this, and will let that stand as my personal defense. I also recommend this post from The Volokh Conspiracy as a useful guide on objectionable material.

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.

However Much an Individual Cares, He Is Correct

CBS News offered the first mainstream article I remember seeing that considers the possibility that male circumcision may be genital mutilation without at least cushioning the psychological hit by putting mutilation in quotes. That’s worth applauding, even if some of the article should be better. For example:

As for circumcision’s effects on sexual function, several studies conducted among men after adult circumcision suggest that few men report their sexual functioning is worse after circumcision. Most report either improvement or no change, according to the CDC.

This is not an acceptable summary of these studies since they show more variation than the reporter suggests here. For example, if a study reports that 18% of men aren’t happy with the results of circumcision, that qualifies as more than “few men”. This approach also fails to explore the assumptions in reaching those results that may be questionable. Self-reporting and why the respondent chose circumcision likely factor into the individual’s conclusion in some manner. But even if “few” is correct, ignoring individual conclusions about sexuality misses the ethical principle involved. Generalizing in place of considering what the individual male might want does not, therefore, justify applying the preferences of a majority onto any individual. (And I can uncritically provide studies (pdf) that reveal the opposite of the article’s statement.) Does the individual male child want to be circumcised? No one can know, which is why his lack of need is what matters.

The article concludes with this, a common misguided analysis.

“People care way too much about this little piece of skin,” Dr. Mark Alanis, assistant professor obstetrics and gynecology at the Medical University of South Carolina in Charleston, who has written a history of circumcision, told the Washington Post. “At the end of the day, it’s unlikely to significantly change your child’s life for better or worse.”

Unlikely is not certainty, which demonstrates that this discussion must include ethics. All males will suffer some level of objective negatives, since no surgery is free of harm. A few will suffer worse objective negatives than the typical circumcision. These facts are indisputable, and suffice to rule out the imposition of non-therapeutic circumcision on a child. Dr. Alanis ignores that.

In his quote, he dismisses the subjective aspect of individual preference. Many males have – and will continue to – conclude that there are subjective negatives in addition to the objective harms of circumcision. He has no more standing to state that I care too much than I say he cares too little. The correct analysis is that I care about myself and he cares about himself. Each viewpoint is valid, but only as it applies to ourselves. Where he thinks circumcision is minor, I think it is major. Where he states it is a “little piece of skin,” I state that my foreskin was my little piece of skin. Rights matter. That’s where the emphasis must be.

Beyond ethics, his argument misses a larger issue. The burden of proof rests with people who want to circumcise children. But the correct test is need, not possible benefits. So, when advocates of non-therapeutic circumcision suggest that it doesn’t matter, the follow-up against this argument is why the advocate insists on permitting (or encouraging) circumcision. If it’s not important either way, then the superior option is that which doesn’t harm and maintains future choice. The response to that approach is generally a recitation of the claimed potential benefits, whether medical or cultural. Although only one justifiable conclusion exists, considering those is a better approach because it requires thought. In that willing participants can recognize that there are reasons to prefer being intact and that intact males aren’t destined to death-via-foreskin or even the rare medically necessary circumcision.

The “it doesn’t matter either way” approach is nothing more than declaring that one’s own personal, subjective preferences are universal and “right”. It’s a form of arrogance masked as an indifferent, considered statement of scientific fact. It is not. It is an opinion based on a subjective evaluation of competing thoughts. The only appropriate person to make that decision is the person who would be circumcised.

“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.