Circumcision – Page 17 – Rolling Doughnut

Subjective evaluations require only the individual.

The mindlessness of both research and reporting about circumcision is exhausting. I fear this story is going to be the new gold standard for the smug dismissal of any challenge to pro-circumcision advocacy. Consider:

Circumcision does not reduce sexual satisfaction and so there should be no reservations about using this method as a way to combat HIV, a study says.

Nearly 5,000 Ugandan men were recruited for the study. Half were circumcised, half had yet to undergo surgery.

There was little difference between the two groups when they were asked to rate performance and satisfaction, the journal BJU International reports.

Ehhhhhhhhhhhhh. The ways this is going to be abused by those who’d rather cheer their reality-free position than think their way into an honest conclusion that recognizes medicine and ethics…

Sexual satisfaction is a subjective measure, unique to each person. Collective judgments are irrelevant.

The men in the study are adults volunteering for the surgery. Don’t read more into it than that.

These results do not change the medical and ethical issues surrounding infant circumcision.

There is a difference in the skin of a freshly healed circumcision and a circumcision that occurred in infancy many decades ago. The former is still pink and moist. The latter is keratinized and tough. This is not open to debate.

Par for circumcision ~~advocacy~~ reporting, the article immediately restates that (volunteer, adult) circumcision may reduce the risk of female-to-male HIV infection. It leaves out most of that specificity, of course. Consider what the journalist reports on how (voluntary, adult) circumcision may achieve this result.

Specific cells in the foreskin may be potential targets for HIV infection, while the skin under the foreskin may become less sensitive and less likely to bleed – reducing risk of infection – following circumcision.

In any other academic pursuit, such obvious contradictions would be called out and the position advocated on faulty thinking would be dismissed. These two claims conflict. (Voluntary, adult) circumcision doesn’t affect sexual satisfaction, but it might reduce sensitivity. So which is it?

Still, we must focus on circumcision as an individual procedure. The study found the following:

Some 98.4% of the circumcised men reported satisfaction, compared to 99.9% in the control group.

And so on, with the reported caveat that these differences aren’t clinically significant. That doesn’t matter for the individual.

I don’t have the numbers, so I’ll use assumptions based on what’s reported. I’ll assume 5,000 adult men volunteering for the study, with 2,500 in each group. So, of 2,500 voluntarily circumcised adult males, 2,460 are happy with the results. That leaves 40 men who are not satisfied. For those 40 men, they can claim “oops” and have that suffice. If the study’s findings hold for infant circumcision, which I doubt on a one-to-one comparison, “oops” is not sufficient to justify the implied harm done to those 40 males circumcised as infants at the decree of their parents.

The Obvious Drawback to Educating Via Lists

This article demonstrates how most media irresponsibly reports on issues surrounding infant circumcision. The Pro list:

Reduces risk of urinary tract infections.

Reduces risk of contracting STDs (still under debate. A recent study in South Africa found that circumcision may reduce HIV transmission, but the study was not completed.)

Reduces risk of penile cancer.

The caveat on point two is shocking because most media outlets are far too breathless to include that. But notice the complete lack of context on the risks listed. The article mentions a bit of context that the actual risk of UTIs and penile cancer are tiny, so why not include that in the list? The support becomes even less compelling when context is included.

The Cons:

The foreskin is densely packed with nerves and blood vessels and forms a protective covering over the head of the penis. It also provides lubrication. Many advocates claim that removing it therefore reduces sexual sensitivity.

Circumcision has led to complications from excessive bleeding and infection in the past. But many say that complications resulting from circumcision are far fewer than those averted by it.

I don’t believe the qualification on point one is necessary. The basic fact leads to one logical conclusion. Anecdotal evidence also seems to readily verify this statement. But I understand the contention over the issue.

There is no excuse for the qualification in the second point. Circumcision is an individual surgery. The risk of complications applies to each individual circumcised, regardless of the reason. People believe that circumcision is safe. I’ll set aside my factual claim that it causes harm in 100% of instances and accept that such a belief is statistically supported in the collective.

But complications occur. It is not fool-proof. The existence of inherent surgical risks requires that we bring the issue to medical need alone. Adding the caveat permits people to incorrectly believe that the potential benefits outweigh the potential complications. (Risks are not potential.)

Also, since no context is offered for the earlier benefits, stating now a conclusion from a cost-benefit analysis is poor journalism. If the article does not provide the analysis, it can’t responsibly provide the conclusion.

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The article concludes with this:

Dr. Stephen Wainer, a pediatrician at the Peter Lougheed hospital, feels many people are giving the issue more attention than it’s worth.

“In the greater scheme of things, it’s a trivial issue,” says Wainer, who routinely performs circumcisions.

Perhaps it’s interesting that Dr. Wainer believes unnecessary infant circumcision is a trivial issue. So what? His patient’s opinion is the only opinion that matters. Dr. Wainer doesn’t ask his patients because they can’t give their opinion. Their opinions may be no less subjective that Dr. Wainer’s stance, but that doesn’t matter. The patient’s opinion is the only opinion that medically and ethically matters.

The debate ignores this, but honesty would acknowledge it.

Fill in the blank:

“I didn’t feel nervous, because I had spent years watching how the cut was done,” [Amina] Khidir remembers. “And my was a baby at the time, too small to understand what was happening. That’s the best age to do it.”

The missing word is daughter.

Asked about the specifics of the procedure, she covers her face with her loosely worn headscarf. “I cut about a quarter off,” she says.

How do we (correctly) label females as victims under that logic, yet males subjected to identical logic and outcome are not victims, but rather the beneficiaries of compassionate parents?

How should we define sexual violence?

I’m still organizing my thoughts on the political chaos in Kenya, so I don’t have much coherent to say on it right now. I’m not sure when or if I’ll write anything more specific to the topic of this entry, but there is a larger issue here that has been ignored for too long. The current situation makes it worth discussing, though. For now, this story will suffice:

Sexual violence has also been reported against men, with the Kenyatta National Hospital in Nairobi on 2 January saying several men had been admitted after they were assaulted during the violence.

“There are several men admitted in various wards after they were subjected to forced circumcision,” a source at the hospital said.

[Challenger Raila] Odinga’s core supporters come from the Luo ethnic group that does not practise circumcision, while [incumbent President Mwai] Kibaki draws most of his following from the Kikuyu group, one of several tribes in which male circumcision is an essential rite of passage from adolescence to manhood.

Like I said, I’m still working on a macro-level analysis of what the current unrest means. I don’t have enough information right now, so I won’t speculate. But the micro-level question is undeniable. How is the forced circumcision of infant males any different from the forced circumcision of these adult males?

The answer offered will surely rest on intent. This is a valid discussion point in many instances, but intent can’t be relevant in unnecessary, forced circumcision. These adult men clearly have not sought circumcision before, and they didn’t seek it now. They are now the victims of (sexual) violence.

In contrast, the parents of infant males do not seek to impose violence on their son when they have him circumcised. That does not negate the imposition of violence that occurs when they have him circumcised. If left alone, he would not likely choose (or need) circumcision in his lifetime. Any decision to the contrary fails to meet any standard of reasonable. The mere presence of good intentions is a subjective attempt to validate what is at its core a violent, unnecessary intervention on the body of a healthy individual.

The answer will probably also include an incorrectly-nuanced nod to a difference in rights between children and adults. That can’t withstand scrutiny, either. The reason the violence inflicted upon these Kenyan men is problematic is because it is a human rights violation. Too often advocates of circumcision ignore human. Children are humans, too. Their rights do not magically appear at the age of majority. They exist from the child’s birth. Each child possesses the very same basic right that was violated in these Kenyan adult males.

Given that I don’t think I’ll find anyone to defend what was done to these men¹, I’m left to conclude that there are four categories of sexual violence, with one subtle difference.

Sexual violence against women is bad.
Sexual violence against men is bad.
Sexual violence against girls is bad.
Sexual violence against boys is usually bad.

No potential benefit or belief in good intentions or deference to parental rights superseding a child’s human rights can validate the inclusion of usually in the last category. Sexual violence is sexual violence, regardless of gender or age.

¹ I’m sure I can find someone who will say these men will now be better off, a subjective speculation. Pro-circumcision advocacy knows some very strange boundaries. I’ve seen strange boundaries among those opposed to infant circumcision, although I do not believe I appproach them. Yes, I know I’m insulated from a completely unbiased, critical analysis of my own thinking.

Ignorance when buying won’t prevent the pony from biting.

Gary Schwitzer, an Associate Professor at the University of Minnesota School of Journalism & Mass Communication, provides the best explanation for why most reporting on health topics are irresponsibly incomplete. His critique reviews TIME’s year-end medical breakthrough list, which placed circumcision and its ability to “prevent” HIV at the top.

We believe that with any claim of “breakthrough’” the claimant should include some discussion of the quality of the evidence behind this claim. And for stories that discuss treatments, tests, products or procedures, we should be talking at least a little bit about how much these “breakthroughs” will cost.
…

Yes, we know that editors think these lists are cute, promotable features. But the cumulative effect of discussing breakthrough after breakthrough without any mention of cost or evidence leaves the reader waiting for Santa to arrive with the next one.

Any look at how (voluntary, adult) circumcision can reduce the risk of female-to-male HIV transmission must include the costs, risks, and ethical issues, with an honest contextual analysis of statistics. Without that, parents in America will irrationally apply findings to their own children and commend themselves for being so smart. It’s a national farce encouraged by sloppy journalism (among many problems).

Link via Kevin, M.D. The title of this entry refers to this commercial.

Claiming victory is not the same as earning victory.

I stumbled upon an interesting list today at a site claiming to offer “News and Information on all aspects involving
Male Circumcision”. I was already aware of the site and its irrational support for infant male circumcision, so I’m not particularly surprised by this new-to-me list. I will not link it directly, but feel free to peruse the stupidity (http://www.circumcisioninfo.com/circ_record.html#anchor13r) encompassed within the full list. It’s tilted “DEBUNKING THE MYTHS AND LIES MADE BY THE ANTI-CIRCUMCISION CULT”. Judge for yourself how well this pro-infant circumcision site debunks anything other than the pretense that its author is a credible sources of fact.

Allegation 13: Infant circumcision violates the (human) rights of the the [sic] child since it is done without his consent.

From the day that a child is born until it is old enough to make its own decisions, it is the responsibility of the parents to look after the welfare of their child. This means making decisions that they believe will be in their child´s best interest. If parents are convinced that circumcision will benefit their child, they have the legal and moral right to make this decision for him. … [emphasis in original]

Why refer to the child as “it”? “It” is clearly a “he” in this discussion. Do not disassociate the truth that the child is a person from the discussion of what will be done to him by others. Treating him like an independent person with his own opinions may lead to a different outcome. This is why many pro-circumcision advocates seek to circumcise infants. They know most males will opt against circumcision if they’re left with their choice. If advocates have to force an action onto someone for it to persist, the action is most likely illegitimate.

Of course his parents are responsible for his welfare. They can’t refrain from feeding him, or sheltering him, or any other standard of humane treatment. However, intervention outside of daily necessity requires that he have an underlying medical need. When circumcised, his foreskin is healthy. There is no medical need. Circumcision is beyond the realm of reasonable decisions parents may make for a healthy infant.

The troubling part of this attempted debunking is the final sentence I’ve excerpted. Look at the standard. There is nothing beyond parental intent. The parents merely need to be “convinced” about circumcision’s potential benefit to the child at some point in his unknowable future. This is a pathetic attempt at logic. This same unexamined trust in the wisdom of parents would permit female genital cutting, as well. Again, the parents only need to be convinced that it will succeed at achieving some nebulous outcome at some point in the future. Evidence – the standard for science – is absent.

This argument fails to surprise, of course. Parents determined to ignore the evidence of their ~~child’s~~ son’s healthy genitals will happily nod at an excuse that claims to validate their (illegitimate) legal and (alleged) moral rights. There is no regard for the boy’s natural human right to remain free from unnecessary harm. As long as he is healthy, circumcision is a violation. If his foreskin becomes a problem, circumcision is only valid if no less invasive solutions will work. Outside of that rare scenario, any surgical intervention on a child’s genitals is an unethical, immoral perversion of the parent-child hierarchy.

Parents are guardians, not owners. The child retains his rights.

We should value critical thinking skills more.

How do people get so stupid that this passes muster as an excuse to circumcise a child?

Ultimately, a friend who works in elder care made the difference, by describing some of the horrible foreskin infections she has had to treat in older patients.

When my grandfather was in his last days, several veins in his legs collapsed from the damage of smoking for too many years. His doctors had to address this and there were no pleasant options. Still, I would never think to use that as an excuse to perform intrusive procedures on the legs of a child. The logic is equally flawed.

The only lesson to be learned from “horrible foreskin infections” in men in elder care is that those facilities are horrible at caring for their patients. Removing a child’s healthy foreskin because it might become a problem if he ends up in incompetent elder care many decades later is irrational.

A dose of common sense.

Newsweek interviewed Dr. John Bartlett, chief of infectious diseases at Johns Hopkins, for its article “2007: Another Year of AIDS“. I know, with a title like that, how could the reader not be optimistic? Anyway, I think this is useful to note:

So how are we faring in lowering HIV transmission rates?
There are some promising studies that have been done or are being done now. The circumcision and the antiretroviral therapy for [HIV-positive] breastfeeding women [to prevent transmission to the baby] studies were a great success. Though, while circumcision might be very good at lowering the rates in places where not a lot of circumcisions are being done now, that’s not the case in the U.S. or in many other countries …

Advocates of forcing circumcision onto sexually-inactive infant males to prevent HIV always notice the first part of Dr. Bartlett’s statement and ignore the qualification that the U.S. does not meet the criteria from the studies everyone is now touting.

And notice the use of “might be very good” for non-circumcising nations, an acknowledgment that (voluntary, adult) male circumcision is not a vaccine. Looked at honestly, circumcision is little more than a distraction from the problem and its real cause(s).

There is no right to designer children.

Via multiple sources, but with public commentary from Rogier van Bakel, here’s a maddening story with at least one comparison I will make.

DEAF parents should be allowed to screen their embryos so they can pick a deaf child over one that has all its senses intact, according to the chief executive of the Royal National Institute for Deaf and Hard of Hearing People (RNID).

Jackie Ballard, a former Liberal Democrat MP, says that although the vast majority of deaf parents would want a child who has normal hearing, a small minority of couples would prefer to create a child who is effectively disabled, to fit in better with the family lifestyle.

Ballard’s stance is likely to be welcomed by other deaf organisations, including the British Deaf Association (BDA), which is campaigning to amend government legislation to allow the creation of babies with disabilities.

A clause in the Human Tissue and Embryos Bill, which is passing through the House of Lords, would make it illegal for parents undergoing embryo screening to choose an embryo with an abnormality if healthy embryos exist.

To fit in better with the family lifestyle. The similarity to permitting parents to surgically alter the healthy genitals of their male children for any or no reason is exact. Harming the child – and cutting off healthy bits of his genitals or deliberately selecting an embryo because she will be deaf is harm – so that he or she meets the parents’ expectations of valid physical characteristics is immoral. It should not be allowed.

As Mr. van Bakel wrote¹:

For about two seconds, I tried to apply some libertarian gloss to the situation — parents making up their own minds about their offspring, how bad can that be? — but it just wouldn’t stick. Um, what about the right of the child to be normal (no, that’s not a pejorative word) and healthy?

Indeed. In a world of individual rights, the child matters first and only.

He continues:

These people are truly a bunch of, hell I’ll say it, immoral imbeciles. They want a child with a deliberately-bred disability because junior would “fit in better with the family lifestyle”? Great. It follows … that we should defer to legless parents who decide to have their obstetrician snip a couple of limbs off the foetus.

As one commenter at Nobody’s Business noted, we already (irrationally) defer to parents who decide to have their doctor² snip the healthy foreskin off their newborn son. There is an obscene, ongoing precedent for such abomination.

Top Ethical Breakthrough, circa 1776: Individual Liberty

Time announced its year-end list. While everyone else is in freak-out mode about Putin being named “Man of the Year,” I’ll be in my corner noticing the perpetuation of the same silly myths through omission and a refusal to question. The top “medical breakthrough” of the year:

Circumcision Can Prevent HIV

In December 2006, the National Institutes of Health halted two clinical trials of male circumcision after an early review of the data showed that the procedure dramatically reduced transmission of HIV. Early this year, the details of those studies were published in the Lancet: In the two randomized trials, which included 7,780 HIV-negative men in Rakai, Uganda, and Kisumu, Kenya, researchers found that medically circumcised men were at least 51% less likely than uncircumcised [sic] men to acquire HIV during sex with women. The editors of the Lancet called the discovery “a new era for HIV prevention.” Scientists don’t know yet whether male circumcision can also provide protection for female partners — a new study on the hypothesis is forthcoming next year.

Aside from the general [sic] surrounding “prevention” in the title of its story, Time’s joined the mass blindness and ignored the two key words in the study, voluntary and adult. The glaring ethical problem created from the ommission of those two words means nothing, apparently. Of course, neither does the truth that researchers do not know the specific cause of this alleged benefit for men who engage in unprotected sex with HIV+ women, so I’m not going to fake surprise at this reporting.

Time’s reporting also ignores the potentially greater benefit provided by safe-sex education and the inherent fallacy in looking at data from a 21-month period in which the circumcised men were asked to refrain from sex for 6 weeks after the surgery and the latency period for the disease is up to 6 months. What’s 7.5 months over the long stretch of 21 months?

Please note that Time ranks this revelation ahead of such breakthroughs as a Test for Metastatic Breast Cancer, First Human Vaccine Against Bird Flu, and Early-Stage Test for Lung Cancer.

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In related news, Time named this the top scientific breakthrough of the year. Now is a great time to mention how this improves the ethical debate. Instead of using human embryos, molecular biologist James Thomson figured out a way to create stem cells from “regular skin cells”. From Science Magazine (pdf):

Instead of cells from adults, Thomson and his team reprogrammed cells from fetal skin and from the foreskin of a newborn boy.

It’s a good thing we’ve resolved all the ethical issues in the stem cell debate, because taking the healthy skin of a living infant male is much better than taking cells from an embryo that will never be a living human. (Listen to an NPR interview on this story, with mention of Thomson’s use of an infant’s foreskin, here.)