Category: Circumcision

I’m on vacation, so I shouldn’t be blogging this. However, vacation is the only reason I’ve waited as long as I have. William Saletan is wrong on circumcision. Consider:

For thousands of years, we humans have lovingly mutilated our children. We give birth to them, swaddle them and then cut their genitals. Some people condemn these rituals; others defend them. Now reports from Africa are shaking assumptions on both sides. Our mutilation of girls may be killing them. Our mutilation of boys may be saving their lives.

Read that with an ounce of logic and it’s clear where his analysis is lacking. The manner in which humans practice the two forms of mutilation dictates that, not the validity of the surgical procedures. We cut girls to an extreme not generally practiced on boys. But the qualitative comparison, the surgical alteration of a non-consenting child without immediate medical indication, is the same. The quantitative analysis so favored by those dismissing that comparison does not change its validity. Pretending that quantitative analysis alters that is the folly that offers protection to girls while boys must surrender healthy foreskins to avoid potential problems that will most likely never materialize.

In discussing the growing movement to protect boys legally, as girls are now protected in the United States by the Female Genital Mutilation Act, Mr. Saletan offers this challenge:

But scientific rebellions against religion have a nasty habit of becoming religions themselves. First come the myths. Last month, Dan Bollinger, director of the International Coalition for Genital Integrity (ICGI), launched Project: OUCH!, a “collection of first hand accounts” by victims of genital mutilation. The first account, written by Bollinger, described a recurring “flashback of my circumcision when I was three days old.” It was a moving story. But according to brain researchers, such memories at that age are impossible.

I’ve read Mr. Bollinger’s site, although I offer no opinion on the validity of his flashback. My only belief is that both sides should exercise skepticism. Until recently, accepted medical opinion stated that infants do not feel pain. However, the higher burden rests with those who wish to circumcise infants. Their position involves the permanent removal of healthy tissue without the consent of the patient. In any other medical decision, doctors would refuse to conduct such an operation. Yet, male circumcision gets a free pass, even though it is radical surgery. Whether it’s religion, societal norm, or potential benefits, supporters must exercise caution. The ethical implication must be included. It is most often ignored.

Then comes the ideology. Foreskin advocates say uncut men are “intact,” “natural” and “normal.” Circumcised men, by implication, aren’t. Technically, according to Doctors Opposing Circumcision, it’s up to you whether to “go through life with incomplete genitalia.” But what kind of man would choose that?

Uncut, or uncircumcised, implies that cut is the normal, correct state of the penis; the foreskin at birth is simply a defect to be removed. This is wrong. We do not say that clothes are undirty after we wash them. This is why you see [sic] after uncircumcised in my entries. They sound ridiculous, but unintact, unnatural, or unnormal better describe the circumcised penis. Circumcision is common, not normal. If that makes me guilty of ideology, fine. But, again, the burden of proof lies with those who wish to cut.

As for Mr. Saletan’s rhetorical question, I’m not sure how he can approach that question and then not challenge the assumption that male infant circumcision is reasonable. The fact that the majority of the intact adult population never needs circumcision, nor seeks it, is telling. So why do we believe that it’s reasonable to circumcise male infants? (Mr. Saletan returns to this in a few paragraphs.)

Half the time, anti-circumcision activists talk like antiabortion activists. They’re pushing federal legislation that would impose a prison sentence of up to 14 years on anyone who “cuts or mutilates the whole or any part” of the foreskin of a boy younger than 18. (Call it the “partial bris” bill.) They’re planning lawsuits to intimidate doctors and ban infant circumcision.

The language Mr. Saletan mocks is already in the Female Genital Mutilation Act. Worth noting.

The rest of the time, they talk like radical feminists. They’re outraged that we deplore female mutilation but tolerate male circumcision. They call this sex discrimination and a violation of the Constitution’s equal protection clause. The ICGI has even proposed an international legal code equating removal of the foreskin with removal of the clitoris.

Have these people lost their heads?

“Guilty”, but that’s not my point for excerpting that text. Removal of the foreskin is not equivalent to removal of the clitoris. I do not need to push that fallacy to make my point. Removal of the foreskin is similar to removal of the clitoral hood or the labia¹. Type I female genital mutilation without excision causes no more damage than male circumcision². Should we allow that, since quantitative analysis seems to be all that matters? The answer seems to be yes, unless supporters of male infant circumcision wish to finally stop arguing the foolish notion that female circumcision is heinous, while male circumcision is parental choice. Hypocrisy or female genital mutilation. Supporters of male infant circumcision choose one or the other with their stance.

The stakes in that question are becoming deadly serious. Of the 5 million people who contracted HIV last year, two-thirds lived in sub-Saharan Africa. Four years ago, the U.S. Agency for International Development analyzed 38 studies, most in Africa, and concluded that circumcised men were less than half as likely as uncircumcised men to get HIV, apparently because of the susceptibility of foreskin. Last fall, a randomized controlled trial in South Africa found that circumcision reduced female-to-male transmission of the virus by 60 percent. “Male circumcision provides a degree of protection against acquiring HIV infection, equivalent to what a vaccine of high efficacy would have achieved,” the authors wrote. It was, they observed, “the first experimental study demonstrating that surgery can be used to prevent an infectious disease.”

It’s easy to “win” your argument by throwing out impressive statistics. Consider:

RESULTS.–We observed one probable instance (1%) of female-to-male transmission compared with 20% transmission rates in the female partners of infected men. All couples were sampled in the same way. Male index cases were more likely to be symptomatic than female index cases. CONCLUSION.–The odds of male-to-female transmission were significantly greater than female-to-male transmission. The one case of female-to-male transmission was unique in that the couple reported numerous unprotected sexual contacts and noted several instances of vaginal and penile bleeding during intercourse.

I don’t offer this as a definitive gotcha, only as an indication of how statistics may not tell the entire story. The 60% reduction in HIV transmission number is fascinating, but it must be considered in the proper context. Female-to-male transmission is not the most common form of transmission. Why is it acceptable for supporters of circumcision to use the least common³ form of sexual transmission as the sole basis for a radical policy, while circumcision opponents can’t use the least common form of female genital mutilation as the basis for comparing the qualitative and ethical similaritie
s of the two procedures? My position is not the crazy position.

Think about that: surgery as a vaccine. Drug researchers would kill for an HIV vaccine half as effective as circumcision. Condoms and abstinence often aren’t effective because they require diligence. Circumcision works more reliably for the same reason that foreskin enthusiasts hate it: It lasts forever. Using the new data, scientists estimate that over the next 20 years, circumcision in sub-Saharan Africa could prevent 6 million infections and 3 million deaths.

I must beat the personal responsibility drum again. Boys 1 through 999 shouldn’t have to lose a foreskin because boy 1,000 can’t be bothered to wear a condom. The diligence argument is collectivist nonsense, pushing the benefit to the group above the protection of the individual. The Constitution has no exception voiding its protection of individual rights just because irresponsible behavior may occur.

What do you do when mutilation turns out to save lives? Anti-circumcisionists can’t bear it. Years ago, they denied the HIV-prevention effect. When evidence from Africa defied them, they changed the subject to Europe. When evidence from Europe defied them, they changed the subject again. Some say a link between circumcision and HIV can never be proved. Others ignore it. Others insist it’s unethical and false. It can’t be true. It’s heresy.

Mr. Saletan is throwing everything and hoping something sticks. He provides many links to anti-circumcision arguments in the Slate version of his essay. I’ve probably duplicated some of the arguments he tries to diminish. I’m not going to rehash them here, but instead offer the suggestion that doubters use the search feature on the main page of Rolling Doughnut to review what I’ve written about circumcision. Poke holes if you can. I have not denied any results, as Mr. Saletan accuses (indirectly, of course, for he did not link here), nor do I feel denial is necessary..

The strongest argument against circumcising babies to prevent HIV is that they’re too young to consent. But we vaccinate babies all the time. Should we treat circumcision like a vaccine? At clinics across southern Africa, men are lining up, pleading to be circumcised. They want protection. Can we assume their sons would want the same thing?

The comparison of circumcision and vaccination is a diversionary tactic with no basis in reality. We vaccinate against communicable diseases, not individual choices. The former is a public health issue (although we still allow parents to decline), while the latter is purely individual. As such, there is a reasonable explanation for parental decision on vaccinations, while limiting there choice on circumcision to medical necessity. Lack of diligence does not result in polio. Many of the alleged protections for male circumcision have less invasive solutions (i.e., the same ones we use for females), but they also have an element of parents educating children about responsibility and consequences. That is especially true of HIV. But it’s easier to cut.

To the specific example of men lining up, this is wonderful if they choose circumcision because their behavior or their perceived threat of exposure puts them at risk. I have never argued that adult circumcision should not be allowed. I’ve gone so far as to say that men should choose to have themselves circumcised if they believe it will help. Choice is the ultimate issue here. Those men have it. Their sons, and now with another bogus justification, our sons, do not. The lack of a stampede among intact European and American men to have themselves circumcised suggests that their sons would not want the same thing. The child’s cries during circumcision are also a reasonable indicator of his wishes.

Next weekend in Seattle, critics of genital mutilation will convene an international symposium on circumcision. The program lists 40 sessions. Not one mentions AIDS or male circumcision in Africa. Something’s sorely missing from this conversation, and it ain’t foreskin.

That symposium is why Seattle is on my travel itinerary this week. Even though I want to hear everything discussed on Friday, I’m willing to step out at 3:00pm PST for however long it takes to explain to Mr. Saletan “Traditional Male Circumcision in West Timor, Indonesia: Practices, Myths, and their Impact on the Spread of HIV/AIDS and Gender Relations”. That’s on the schedule at 2:40pm. It’s not listed on the schedule, but I’m sure HIV will come up at 4:40pm on Friday during “Circumcision in the Mass Media”. I suspect “Coding, Reporting, and Analyzing Circumcision Data” on Saturday at 9:00am will include some discussion of HIV, as well.

Mr. Saletan thought he was making a point because the discussion does not center on AIDS in Africa. However, he does not indicate that his support for male infant circumcision as an HIV preventive is limited to Africa. Surely he does not believe the two cultures are the same. As such, he is guilty of the same omission of facts that color his argument with shades of grey. Instead of making his point, he demonstrated how circumcision supporters are leaving the foreskin and its functions out of the conversation on circumcision. HIV/AIDS is only one aspect of this discussion.

¹ This editorial by Dr. Paul Tinari posits the following:

The cells of the labia are also susceptible to HIV infection, so what role does female circumcision play in reducing the rate of HIV infection?

I don’t have time to find studies verifying this claim, but it’s worth considering. If it’s possible, should we fund research here? If research finds a link, should we repeal the Female Genital Mutilation Act and begin circumcising infant females? I know it’s preposterous, so why isn’t male circumcision objectionable? Neither or both are the only choices. I choose neither.

² I also have no need to push the belief that Type I without excision is common. It is not. Most female genital mutilations are severe. I offer this example only as proof of our hypocrisy in ignoring any qualitative analysis. For more info on the various types of FGM, click here.

³ I’m excluding female-to-female, even though I assume it’s the least common method of transmission. Since it does not involve a penis, it is not pertinent to this discussion.

Reprinted with one comment:

Just hours before the official opening of the 16th International AIDS Conference last night, [South Africa’s] Health Minister Manto Tshabalala-Msimang whipped up controversy over the best way to treat HIV patients, extolling the benefits of garlic, beetroot, lemons and the African potato.
…

“We have a constitution which says people have choices to make. If people choose to use traditional medicine … why not give them those choices?” said the minister as she opened the Khomanani exhibition stand at the conference. Khomanani is government’s primary HIV/AIDS awareness campaign. Its future is uncertain after the health department failed to issue a new tender for its management.

The flaw in proposing one solution across disparate societies should be obvious.

I’d planned to avoid discussing the mess that is Mel Gibson, but I’m sick of reading this story in all its self-congratulatory incarnations around the blogosphere and want to point out the obvious.

Another talk show host, Joy Behar on ABC’s “The View,” had a more extreme proposal for the actor, whose anti-Jewish tirade during a drunk driving arrest has been a source of incessant talk for a week. “He needs to be welcomed into the Jewish community,” Behar said to whoops of audience laughter, “by a public circumcision.”
…

Behar, who jokingly suggested the circumcision, said in a phone interview later that it’s not just Jews who should be expected to speak. “Any bigoted remarks should be addressed by right-thinking people of all kinds,” she said.

I don’t know the status of Mel Gibson’s foreskin, nor do I care. What’s telling is that circumcision is being used as a sign exclusive to Jews, and it’s clearly intended as punishment for Gibson within the context of the joke. And people are laughing. That somehow makes Ms. Behar’s joke “right-thinking”?

Here’s the obvious. Unless 85% of the American population is Jewish, it’s a tad absurd to equate circumcision with Judaism in America. Jewish? Circumcised. Not Jewish? Intact. It hasn’t worked that way here for more than a century. On that basis alone, Ms. Behar’s joke was stupid. [disclaimer] Yes, I know Gibson grew up in Australia, and his father is an anti-Semite. Both are likely important factors in Gibson’s foreskin status. Again, I don’t think it’s relevant, nor do I care. Ms. Behar wasn’t speaking to Australia. And, yes, I doubt she believes circumcision in America is exclusive to Jews. [/disclaimer]

Seen with the intent of circumcision as punishment, it shows a cruel streak that has no place in this discourse, given the superiority of Ms. Behar’s position with respect to Gibson’s bigotry. Are we to believe that circumcision as punishment has a place in society? I don’t accept that. Of course, I’m biased against the circumcision of non-consenting persons, which I believe fairly explains the basis of the joke’s “humor”. Would people who deem parental choice sufficient to permit routine infant circumcision find circumcision as punishment an acceptable practice? I hope not.

If so, what offenses would constitute sufficient justification? Ignorant speech clearly falls within Ms. Behar’s realm of acceptability, but I wonder what else she (and the people who laughed) would allow. As punishment for masturbation, for example? That’s not far-fetched, given the origins of routine circumcision of infants in America as a preventive protection against the ill-effects of masturbation. So where does it stop? I imagine there’s a line, but I can’t find one that’s civilized in this joke.

Note: I admit that I’m over-analyzing this. It was a joke, said on The View. I get that. But some of those women (and men) watching at home will have kids in the future. Kids will include boys, whose foreskins will be at risk due to irrational adult behavior. Many of those future parents already believe surgical amputation is a valid pre-emptive response to the fear of treatable conditions. We shouldn’t further degrade the public debate with nonsensical jokes that pretend circumcision is funny, or that circumcision as punishment is an intelligent response to bigotry.

Remember, the argument is that male and female circumcision are not the same, despite evidence that justifications are often the same.

Although female genital mutilation among the Pokot is a threat to girls’ education girls are keen to undergo it, the district Vice- Chairperson in Charge of Children Affairs, Ms Helen Pulkol, has said.
…

In her view, parents sometimes influence the practice, but the girls too are interested in the practice and are inspired more by peers.

I’m in no way objecting to Ms. Pulkol, as the article later explains that she’s working to end female circumcision. It’s just useful to remember that cultural influence is powerful, and when parents start with irrational adherence to the opinion of others instead of logical acceptance of normal anatomy, harmful practices and violations continue. Change female to male and Africa to America and the argument remains unchanged. That isn’t a sweeping revelation, of course, but it is another data point demonstrating that violations of genital integrity are not unique to one gender.

I read a lot more than I could ever or would ever post here about the recent studies linking circumcision to HIV prevention. My basic opposition to using that possible link hasn’t changed. It’s illogical to assume that the future, possibly risky sexual activities of a newborn should force a decision on his genitalia so prematurely. Such an irreversible decision should be delayed until he can decide. Nothing has changed in my stance.

Today, though, I thought of an example. Using basic generalizations, most new parents won’t have to worry about their child engaging in sexual activities for 15 to 20 years. Maybe a little optimistic, as I’m sure most will skew to the earlier range, but the point is the same. This long time frame gives science a chance to catch up. It also provides parents with a huge window in which to sneak in a few lessons in responsible personal behavior and the power of unintended consequences, but parents have mostly bypassed that in the nascent rush to change their reason for circumcising. The underlying desire to cut remains unchanged.

Here’s the example which shows the flaw in that rationale. Almost 15 years ago, I sat in my brother’s dorm room with a group of friends. We’d all heard there would be a shocking press conference. When it finally aired, we all watched as Magic Johnson retired from the NBA because he was HIV-positive. None of us could believe it, because more than losing one of the game’s greats, we knew his announcement was his own death sentence. He had HIV, which meant a horrible death from AIDS was soon to follow. That was the accepted wisdom.

Today, 15 years later, Magic Johnson is very much alive. He returned to the NBA twice, and now owns a successful chain of movie theaters. To my knowledge there are no indications that he is hampered or near death. Science caught up enough to keep him alive. More than that, his life isn’t merely an existence held together by machines and hospital beds and inactivity. He’s living with HIV. Where it used to be a death sentence, he can now manage his disease. I imagine it’s worrisome, but we no longer operate under the assumption that it must be fatal, and imminently so. That’s the power of science.

So, knowing that we’ll likely make significant progress in the next 15+ years, no one should use a possible correlation between HIV and the male prepuce as an excuse to abandon common sense. Life will always have risks, but those risks can be mitigated by responsible behavior. Responsible behavior can be taught and learned at any age. Given that the foreskin, once removed, can never be replaced, surgical amputation is extreme by today’s standards. But today’s standards are the wrong measure when dealing with infants. The future is where HIV risk will be relevant to today’s infants. Parents should look there and imagine what the answer should be.

Whatever it is, the answer is not circumcision today.

Today is the first I’ve ever heard of breast ironing:

Worried that her daughters’ budding breasts would expose them to the risk of sexual harassment and even rape, their mother Philomene Moungang started ‘ironing’ the girls’ bosoms with a heated stone.

“I did it to my two girls when they were eight years old. I would take the grinding stone, heat it in the fire and press it hard on the breasts,” Moungang said.

“They cried and said it was painful. But I explained that it was for their own good.”

“Breast ironing” — the use of hard or heated objects or other substances to try to stunt breast growth in girls — is a traditional practice in West Africa, experts say.

Normal anatomy puts the child at risk. The incorrect question, which is the only one asked, is not unique. Do the potential benefits of physical alteration (avoiding sexual harassment and rape) outweigh its harmful effects (physical damage, future health complications)? Is that reasoning familiar? How about this?

“You ask me why I did it?” said Moungang. “When I was growing up as a little girl my mother did it to me just as all other women in the village did it to their girl children. So I thought it was just good for me to do to my own children.”

African girls and American boys aren’t that different. Both seem to be the property of their parents, the integrity of their bodies at the mercy of the flimsiest whims of their parents. Subjective standards allegedly justify a bizarre cultural practice, and as such, allow its imposition. It’s considered normal. Good, even. As outsiders, we condemn it for the unjust violation it is, while ignoring the equivalent violation in our own hospitals. Or we feel it’s not our place to say something because who are we to force our beliefs on another culture?

Meanwhile, the mutilations continue.