Category: Circumcision

Come back when you conform (and prevent HIV).

Yesterday, I found this frustrating article from an e-mail list I’m on. It’s in French, which I don’t speak, so I relied on a rough translation from the e-mail list member who sent it. Danielle verified that the translation I received is accurate as a literal translation. Any errors are as I received them, but I accept responsibility for any inaccuracies.

A Kenyan secondary school dismissed 20 pupils because they were not circumcised, fearing that they should be the object of mockery or violence on behalf of comrades, in this country where certain communities estimate that keeping ones foreskin is not hygienic, one learned Sunday from official sources.

The persons in charge for the secondary school for boys of Kiriani (Eastern Province) addressed to the parents of the 20 pupils a letter announcing their exclusion to them and asking them to proceed to the circumcision of their children so that they can take again the way of the school.

“This to inform you that your son may not present himself at school under the condition where he happens to be. You succeeded in registering your son in our school without informing us that he was different from the others, i.e. non-circumcised. You are requested to do the necessary within two weeks and to present yourself at school with your son as soon as he recovers” (after the operation), can be read in the letter of which AFP obtained a copy.

The circumcision is not compulsory to register in a school, but the headmaster of the college of Kiriani, F. NR. Githinji, explained that the pupils had been dismissed to prevent them from being the object of harassing on behalf of older pupils.

That kind of conformity, even if it’s more extreme than would occur here, is no different than the basic mentality in the United States among parents who circumcise to avoid any locker room embarrassment. It’s easier to teach children to conform through forced bodily modification than to disregard the opinion of another, future teenager. In any other context, we would see this for the fallacious joke it is. But we accept incorrect ideas about the male foreskin without question because we refuse to reject old ideas.

Here’s an idea: if the intact boys will be in a situation where their intactness will be apparent and subject them to harassment, the school has an obligation to protect those boys. It can’t shirk this obligation by sending them home for unnecessary genital cutting.

The related English-language version, courtesy of the BBC, is much shorter, without some of the critical details. That could be an editorial decision to present “just the facts,” but I don’t think so. One daft deft addition to the original article shows that there’s a bias. I’m not sure it’s designed to be “balanced” or to not present this school’s decision as the obscenity it is, but it exists.

Circumcision is not obligatory for admission to secondary school, but a study released in December said it reduced the risk of contracting HIV/Aids.

That’s not related to this story in any way. The BBC’s editors decided that this nonsensical mantra should be repeated. This is how irrelevant scientific ideas get pushed. The logic against circumcision as an HIV preventive and any cost-benefit analysis based in reality is simply inconvenient and not appropriate for the article (or any BBC coverage, for that matter). The BBC skewed the story in its attempt to provide a justification for the school’s irrational action instead of presenting the facts. Now people will read this story without thinking and agree that, yeah, the school’s action is a bit extreme, but it’s okay. They boys will be protected from HIV, in addition to the ridicule they’ll allegedly now avoid.

This is bullshit. The BBC should be ashamed.

Update: A Kenyan newspaper published an editorial against the principal’s decision. Kenya’s education minister George Saitoti said that the principal will face disciplinary action.

¹ Not incorrect, just irrelevant. It’s relevant to adult males, if they choose it for themselves. Until baby boys start having unprotected sex with HIV-positive women, or circumcision reduces HIV transmission through blood transfusions and intravenous drug use, circumcision is not indicated for the limited future possibility of a disease with a specific, identifiable sexual behavior.

Irrational Behavior at the Expense of Another

One more this week on circumcision. This time, I’m amazed that people think this way.

Bo’s updated chest x-ray shows improvement but it is not clear, and his ears have not improved at all (and this is after trying two different antibiotics, b/c the first one wasn’t doing anything after 3 days.)

The pediatrician decided to give Bo a shot of Rophin (sp?), this is intended to help not only his ears, but what pneumonia remains in his lungs. He is totally against, as are we, waiting until June, (next available surgery date for Bo’s circumcision), so is doing everything possible to clear up those little lungs BEFORE Friday morning. The ear infections are in no way a hindrance for this surgery, but they are a whole other issue.

We will return in the morning to the ped. for another Rophin shot and if needed an x-ray. We will do what keeps him safe, but at the same time we want this surgery over with on Friday!!! If it clears up his ears in the mean time, that would be great too.

The boy has pneumonia, and the parents’ primary concern for healing it quickly is so that they can circumcise him tomorrow instead of waiting until June? I do not, and will not, understand that. I’m taking only the information I have here, of course, so there may be information that suggests it’s medically indicated. I doubt it. Also, based on the available evidence I have, this doctor is anxious to heal a child so that he can perform unnecessary cosmetic surgery on the child. That’s absurd. His priority is to his patient, Bo, but he wants to heal him so that the parents, who are not his patient, can be satisfied with their son’s penis.

I also have an alternate take on this parent’s conclusion:

PLEASE just pray that God’s will be done. Bo just needs to get better, and if that is first priority, so be it; we will just reschedule the surgery. But we would also like the surgery DONE. SO, may God’s will just take over and Jake and I just be at peace with whatever God’s decision is.

This is a reason why I don’t go off on people with name-calling and targeted swearing. There is some glimmer of reason there. That’s reassuring because I generally assume that parents who circumcise are well-intentioned, even when they embrace the irrational norm far too easily. I think that’s the case here. If these parents believe so strongly, I’m not sure why the possibility that God’s will is that Bo’s penis not be cut is absent from consideration. Circumcision is at least an implicit statement that the natural, normal human male form is unacceptable. If Man is created in God’s image, circumcision should be seen as a direct insult to God, proclaiming Him not perfect.

Thought Experiment

In the past I would probably apologize for this week’s plethora of circumcision posts, but a wise friend reassured me that I shouldn’t be concerned with posting too much on any one topic. The message I took was that I should write what’s relevant and what I’m passionate about. Still, I try to keep the pace slower than “All Circumcision, All the Time.” I won’t pass up discussing the topic, though, when I can illustrate some useful facet or put some context on a point by making a comparison with another story. For instance:

A man who police said entered into a sex pact with his girlfriend and her 15-year-old daughter pleaded no contest to felony sex charges.
…

Authorities say Fitzgibbon’s girlfriend was afraid of losing him while she recuperated from gastric bypass surgery, so she arranged for him to have sex with her daughter for two months.

All three of them allegedly signed a contract that allowed the girl privileges such as piercings and hair dye in exchange for the sex acts. She testified earlier that she and Fitzgibbon had sex two to three times each week for two months last summer.
…

The girlfriend, whose name is not being made public to protect her daughter’s identity, is scheduled to stand trial in February on three counts of criminal sexual conduct.

Nothing needs to be said on this case specifically because the disgusting nature of both adults’ (alleged) actions is readily apparent. While everyone is focused on the behavior of the man involved, the mother’s behavior is equally appalling. But if her action didn’t involving pimping her daughter, would we be outraged? Since her (alleged) action did involve pimping, should we be outraged?

The answer to at least the latter question is simple for most people. It is for me. The distance between what would be allowed with the former versus the latter is not as great as it might appear. With infant circumcision, our societal desire to preserve a non-existent parental right pushes us close to the idea that children are property. I’ve heard parents make that claim to me, that they have the right to circumcise their children because the child’s body belongs to them as they see fit. Most people don’t circumcise from this extreme stance. Unfortunately, the outcome is the same for children boys.

I’m stuck, though, because circumcision is not medically indicated in the overwhelming majority of cases. With respect to surgical need, there isn’t one. Preventive intent is worthless because the protection can’t be known. The surgery is purely cosmetic in its effect. We disregard that and leave this non-essential decision to parents. Because it is non-essential, it should be unacceptable. It’s not viewed as such. Whether we intend it or accept it, boys are treated as property. What other actions would be logical extenstions with that realization? If children are property, why should sex be any less acceptable than circumcision or ear-piercing?

Does the answer change because the story is about a parent pimping a daughter? Would we have the same reaction if a father pimped his daughter to his (the father’s) girlfriend? The answer should be yes, so the question is mostly rhetorical, but can I expect that reactions to my scenario would resemble the distinctions provided when comparing male and female circumcision?

Unacceptable Notions

The United Nations is concerned:

More parents are turning to medical clinics to perform genital mutilation, wrongly assuming that it spares girls physical and psychological damage, a U.N. agency warned Monday.

The U.N. is specifically concerned about girls because it’s full of hypocrites. I’ve discussed that before, so no need to rehash it here. Yet, looking into its concern is informative. In this context, the United Nations is worried that parents are making female genital mutilation (FGM) more palatable by turning it into a clinical procedure. What the U.N. now fears for girls sounds painfully similar to the basic history behind the growing acceptance of male circumcision (MGM) in America. Physicians became the new priests. The technique improved, but the logic didn’t.

The practice leaves lasting physical and psychological scars, in addition to the risks it generates during childbirth, the U.N. Population Fund said.

The comparison between each procedure leaving physical scars should be obvious enough, although far too many people believe the circumcision scar(s) that remain on the penis are somehow normal. As for psychological scars, the only difference I can decipher is that female genital mutilation is often performed on girls old enough to understand what’s being done to them, whereas male genital mutilation in “civilized” countries occurs primarily on those too young to consciously remember the surgery. Many tout this aspect as a benefit.

Obaid also warned that in some nations parents were subjecting “younger and younger” girls to the practice to avoid refusals to participate. Girls generally undergo the rite before the age of 10, often without anesthesia.

If children remembering the surgery is what the U.N. is concerned with, it should cheer these parents for sparing their daughters the memory. Instead, the U.N. correctly gasps at such an obscene development. But why the disparity? Why should girls be protected, yet when the same fact pattern occurs in boys, it’s wise medical practice? In some parts of the world, males are not circumcised until they approach puberty. They’re old enough to remember the anticipatory buildup. Even then, when the comparison is particularly direct, the United Nations (and other organizations) never fail in remaining quiet. Why? I’ve argued before that basic human rights require more than a clean operating room and good intentions. Surely gender does not fall into that realm of more.

In related news, the Population Reference Bureau declared today the 4th International Day of Zero Tolerance for Female Genital Cutting (pdf), complete with a symposium. I don’t link this here to indict their work. I’m sure it’s useful and any effort to end medically-unnecessary genital cutting on unconsenting individuals will generally get my support. But the glaring omission that the other half of the population is equally at risk must be highlighted. At the symposium I attended in August, the organizers focused on non-consensual genital cutting. Boys and girls deserve equal protection from unnecessary surgery.

Remind me how it’s simple and harmless.

Circumcision risks are rare but quite real:

An eight-day old baby sustained serious injuries to his penis during a circumcision ceremony held at a Bnei Brak event hall Sunday evening.

The baby was rushed to the emergency room at the Sheba Medical Center, where he is currently undergoing surgery to stop the bleeding.

In the interest of fairness, also from the story:

“The baby was not in a serious condition and we brought him to the children’s ward at Sheba. I assume that the mohel had cut too much of his penis during the circumcision,” [Magen David Adom paramedic Shai] Pinchas said.

I wonder if the baby boy thinks he’s not in serious condition, given that an extra piece of his penis was removed with the original “extra” skin.

It makes a great spread for toast, too.

Via Kip comes the disturbing but unsurprising news that Texas Gov. Rick Perry signed¹ an executive order that has no coherent public policy justification:

By issuing an executive order, Perry apparently sidesteps opposition in the Legislature from conservatives and parents’ rights groups who fear such a requirement would condone premarital sex and interfere with the way parents raise their children.

Beginning in September 2008, girls entering the sixth grade — meaning, generally, girls ages 11 and 12 — will have to get Gardasil, Merck & Co.’s new vaccine against strains of the human papillomavirus, or HPV.
…

“The HPV vaccine provides us with an incredible opportunity to effectively target and prevent cervical cancer,” Perry said in announcing the order.

“If there are diseases in our society that are going to cost us large amounts of money, it just makes good economic sense, not to mention the health and well-being of these individuals to have those vaccines available,” he said.

As Kip pointed out, becoming infected with HPV does not guarantee cervical cancer. All this will do for public health is prevent a few cases of HPV infection. His grandiose rhetoric to the contrary, Gov. Perry has done nothing quite as dramatic as he claims. Or rather, the dramatic result is not what he now claims.

Kip also pointed out that the key factor in this debate and whether it makes sense to make vaccination mandatory is that “HPV is not casually contagious.” There is no reason to mandate such an action. Boys are not going to enter the doors of George W. Bush Middle School, sneeze, and infect every any girls with HPV. This is over-reaction with no reasonable basis.

The obvious parallel, of course, is infant male circumcision, which has been justified because it appears to have an impact on HPV transmission. Whether or not that prevention is substantial is irrelevant. The core principle when making a permanent change to someone’s body is medical need. Medical need rarely exists in infant male circumcision; likewise, there is no medical need here to force such an action on young girls. There is no public health basis and a highly subjective personal health basis. Behavior can be taught, and like boys with the behavioral negatives that circumcision supposedly cures, some understanding of the individual affected should influence the decision.

This is naked rent-seeking for Merck poorly disguised as social engineering by Gov. Perry. He delivers millions of customers to Merck. What is he getting in return? Gov. Perry should be ashamed.

¹ Note the wonderful headline to the AP story: Texas Gov. orders anti-cancer vaccine. Gardasil is an anti-HPV vaccine. There is an important difference. Gov. Perry is not mandating an anti-cancer vaccine, no matter how well-intentioned he believes his action to be. It’s being sold with that exaggeration to make it more marketable. Unfortunately, there are individuals involved who can’t consent to such politically warm and fuzzy experimentation on their bodies.

Striking the Match

I know I’m overanalyzing with my interpretation of this because I come into the story with a (not really) unrelated bias. I also know that the author’s point is worth considering, that the foundation is a device to discuss a separate issue. But I can’t get past the obvious flawed assumption in promoting the photojournalist’s use of that device.

A photo of a young boy lying expressionless in a hospital bed hung behind Thorne Anderson.

“This is a boy who had a circumcision,” Anderson said. “It was discovered in that circumcision that he had a condition that would not allow his blood to clot.”

“Now, ordinarily this is very easy to treat. You can take regular dosages of a simple blood coagulant and then he can lead a relatively normal life. However, in Iraq, these blood coagulants, which are available everywhere in the third world, all over the planet, were banned from import under (the United Nation’s economic sanctions on Iraq). Because it was conceivably possible that they might be used as a precursor to a chemical weapon.” Anderson said.

“As a result, this 5-year-old kid died right in front me while I was making these photographs,” he said. “It was at that moment that I really became committed to covering the story in Iraq. Seeing this fraud, political conflict reduced to a human level created a frustration that made me want to tell this story.”

Before I step into any additional assumptions, I’m assuming the boy’s circumcision was not medically necessary. The article does not say, so I should not discount the possibility that it was medically necessary. But I will assume it was not; I’m probably correct. And it makes a useful device. (I’ve already addressed the more foundational assumption of ritual circumcision, which is glossed over to the point that it’s accepted by most as required by faith.)

The boy died because of circumcision, not because of economic sanctions that blocked the importation of blood coagulants. I don’t mean to sound cold, but if no one had cut him, the boy would not have bled. If he hadn’t bled that day, he wouldn’t have died that day. Bleeding and economic sanctions were the manner and the catalyst, respectively, of death, but they were not the cause. Circumcision killed that boy. Ignoring this is how statistics misrepresent the true complication rate of circumcision.

Study the behavioral disinhibition of parents.

One thing is not like the others:

Concurrent multiple sexual partners, low condom use, and low circumcision have fuelled HIV/AIDS transmission, a University of Zambia (UNZA) senior lecturer has said.
…

Giving Botswana, which reportedly has a high condom use and a high prevalence rate as an example, Dr Bowa explained that the problem was due to inconsistent condom use.

An individual’s irresponsible behavior will catch up with him, circumcised or intact, which is a nice way of introducing this study:

Background: Evidence for efficacy of male circumcision as an HIV prevention measure is increasing, but there is serious concern that men who are circumcised may subsequently adopt more risky sexual behaviors.

Before continuing, remember that the most recent trials investigating whether or not circumcision reduces HIV transmission ended prematurely because, having analyzed the initial results, the researchers deemed it unethical to continue the study without offering¹ circumcision to the intact participants. Okay, then. With that out of the way, the question is worthy. Will men engage in more risky sexual behaviors after circumcision?

Methods: Using a prospective cohort study, we compared sexual behaviors of 324 recently circumcised and 324 uncircumcised men at 1, 3, 6, 9, and 12 months after circumcision/study enrollment. The main outcome indicators were incidence of sexual behaviors known to place men at increased risk of acquiring HIV, namely, having sex with partners other than their wife/wives for married men or other than “regular” girlfriends for unmarried men.

And the glowing conclusion?

Results: During the first month following circumcision, men were 63% and 61% less likely to report having 0 to 0.5 and >0.5 risky sex acts/week, respectively, than men who remained uncircumcised. This difference disappeared during the remainder of follow-up, with no excess of reported risky sex acts among circumcised men. Similar results were observed for risky unprotected sex acts, number of risky sex partners, and condom use.

Supporters of circumcision – I’m only concerned about those who would force circumcision on infants – as an HIV prevention technique may draw the conclusion that circumcision does not encourage men to engage in riskier behavior. That conclusion is fine, and it gives a positive spin to this study, but it misses the point. The issue is not whether or not men refrain from risky behavior shortly after the procedure. Of course they’ll engage in less risky sex. The nature of an open, healing surgical wound immediately following circumcision almost guarantees that. I don’t need data to know that.

The issue is the long-term effect, especially considering how many now tout HIV prevention as an excuse to circumcise infants. Infants will not engage in sex for years, so the convergence of long-term behavior matters exclusively. If men continue to engage in unprotected sex with HIV-positive women after circumcision, those men will become infected. Regardless of the 50% reduction, the question becomes when, not if.

In our society, in the context of infants, circumcision alters nothing. It offers no change in the need for intelligent sex education. Personal responsibility and behavior will still matter most. However legitimate the protection is, and I have no reason to doubt it, the impact of circumcision on HIV prevention is miniscule, at least in the United States. We must require more than miniscule benefits to justify the risks and rights violation involved in infant circumcision. Every justification short of immediate medical necessity with no less invasive alternatives fails reason and should be discarded.

¹ Not offering the choice to adults is unethical, but taking the liberty to recommend forced circumcision for infants is not. Interesting lack of logic.

Fine-tuning Perspective

In some ways, it’s easy to point at other countries and find proof of how to do things correctly. We’re not perfect, so such analysis can be beneficial. It can also be used as a blunt weapon against the United States. “Anything American is bad”, which could just as easily come from an American as another country’s citizens. Then something comes along to show that, just like brilliance, stupidity knows no bounds. We’re not perfect, but no one is.

Consider:

About one in three healthy baby boys is circumcised on Prince Edward Island, about double the national rate, despite the advice of experts who describe it as unnecessary and potentially risky.

The story offers a little analysis, which is useful (and obvious). That’s not the heart of the story, though. This is:

Dr. Doug Tweel is one of the few Island doctors who perform circumcisions.

“There are many procedures done in the hospital setting that are elective procedures,” said Tweel.

“If you’re coming at it from that perspective, I can give you a lot of procedures that are not medically necessary.”

By virtue of the “Dr.” before his name, I assume Dr. Tweel is an intelligent individual. But, really, can anyone be so mind-numbingly simple? No kidding he can name a lot of procedures that are not medically necessary. Any idiot could do the same. Examples abound all over society in the United States, so I assume the situation is the same in Canada. But how many of these elective, medically unnecessary surgeries do we allow to be performed on infants, at parental request? One, which Dr. Tweel knows. Unless the reporter omitted further comments to the contrary, he seems uninterested in that perspective. As long as we perform it on someone, everyone should be eligible to have it done. Even when it’s forced on them for someone else’s reason.

Okay, if your son is Teddy Roosevelt.

Very often, arguments so stupid as to warrant little more than an eye roll and a click to the next article come along to annoy the intelligent reader. Those are easy enough to set aside. Sometimes, though, someone will make an argument so mind-numbingly pointless that highlighting is necessary in an effort to remind others that such drivel will be exposed for what it is. Today, I found such an argument arrived in my rss feed.

Among pediatricians and obstetricians and some insurance companies, there are few topics that generate more controversy than whether newborn boys should undergo circumcision. In this country at this time it is the most common surgical procedure being done. Having done duty with troops in the tropics, the writer has some very strong opinions about the benefits of this operation, whereas most of the physicians (primarily pediatricians) who are opposed to the routine circumcision of boys seem to have escaped the experience of heat, humidity, dirt, and poor opportunities for good personal hygiene that is often the story in the tropics. Circumcising a 20 year old is a far more formidable procedure than taking care of a 20 hour-old baby. And the 20 year-old will be disabled for duty for about 20 days, which is a great loss to the overall effectiveness of the unit, plus misery for the 20 year-old.

The perpetrator of this irrelevant tangent is Dr. Richard S. Buker, Jr., Health Officer for Liberty County, Montana. That scares me. A doctor providing information to the community should provide factual information for use by patients. This is anecdotal hooey aimed at parents with blatant disregard for the child’s medical needs and rights.

Dr. Buker thinks it’s correct to hold every boy to a standard that might – might – be appropriate in a tropical environment with limited access to proper hygiene facilities. I’m fairly certain that Liberty County, Montana does not meet that requirement. (Money should be spent on proper hygiene facilities instead of circumcision, if that’s a problem.) As for any potential decrease in troop effectiveness if soldiers are intact, Dr. Buker posits that forced surgery on infants is a benefit in case he joins our volunteer army. This is not rational. The boy can have himself circumcised before joining the military, if he so chooses.

Or non-facts:

Good evidence keeps increasing to support the argument for routine circumcision, which people should be aware of. The single biggest recent finding is that HIV/AIDS transmission is 80% less when men are circumcised. The big push in Africa and South East Asia is to get all males circumcised to decrease the spread of this horrible scourge. What works in Africa works here as well.

I’m going to be kind to Dr. Kruger and say that he is mistaken instead of lying when he quotes an 80% decrease in HIV transmission. The rate mentioned in the few studies done so far indicate a decreased incidence of between 50 and 60%. That extra 20% or more is huge, aside from the obvious arguments against the other 60%. Dr. Buker is a public health official. He must get his facts correct. The burden is especially important when he’s advocating unnecessary, permanent alteration of a child’s body.

It has long been established that the statistical risks of circumcision are considerably less that the risks of not being circumcised. Cancer of the penis is almost unknown in circumcised men. Sexually transmitted disease is less common in circumcised males. In the experience of the undersigned, who has served as a venereal disease control officer (in the tropics), chancroid was 80 times as common in uncircumcised males as in circumcised men.

Cancer of the penis is almost unknown in intact men. Sexually transmitted disease can be prevented with condoms and responsible sexual behavior. No surgery necessary.

Urinary tract infections in children under 5 years of age are less common in circumcised males. Paraphimosis (the writer hated getting up in the middle of the night to treat this problem), balanitis, and getting foreskin caught in a zipper can all be avoided by routine circumcision plus it is no fun being teased in the locker room, all of which are arguments for circumcision of newborns. What about arguments against the procedure? It is a bit cruel to overpower a helpless baby and do an operation on him, and like all operations there is a small risk. As all readers will readily have concluded by this point, the writer is highly in favor of the procedure.

UTIs are more common in girls than in intact boys. Paraphimosis (the writer should not be a doctor if he doesn’t want to treat patients) and balanitis can be avoided by procedures less invasive than circumcision. Getting the penis caught in a zipper can happen with or without circumcision. Being teased in the locker room is not a medical condition justifying surgery. The only argument against infant circumcision that Dr. Buker can come up with is that it’s a bit cruel, and there are risks. No kidding. That should be enough, since it’s also medically unnecessary at the time it’s performed.

These are the arguments of a man who’s already made up his mind and is looking for excuses in the face of logic and facts.