Category: Circumcision

Clarifying Circumcision Facts, Part 1

I’ve been in an on-and-off circumcision debate on Twitter recently with an individual named NotStyro. (My Twitter link.) I find the debate useful because I find his responses inadequate. However, 140 characters isn’t enough to debunk the flaws in the link he typically provides. I have a different qualm, but first, a representative tweet from NotStyro on the subject.

just to inform, not debate… [link redacted] …let me know if you would like more information

I find this understandable within the limitations of Twitter, but unsatisfactory overall because the site he links makes this offer:

Why should you consider circumcision ?

With the anti-circumcision propaganda on the net, consider the following facts:

If parents will make a choice (that isn’t ethically theirs), I want more than a list of seven facts of questionable legitimacy. To the extent these facts are facts, they still do not support what NotStyro recently promised a father questioning his son’s pending circumcision to go forward with the surgery:

… he’ll appreciate your decision later in life.

As he’s been in our debate, NotStyro is indifferent to the reality that men, including me, do not appreciate that decision by our parents. This is our fundamental disagreement. I demand only that each individual retain the choice to decide about his body. NotStyro argues differently. But we can’t get to it until we agree on facts.

There’s too much information in his link for one post, so I’m going to break this up into its logical parts. The list NotStyro links to has seven items. Each item will get an entry. Once I’ve posted an entry, feel free to debate (i.e. defend) a position. No e-mail or web address is necessary to comment. I’m establishing only one rule beyond normal etiquette: inappropriate links will be deleted. Most links will stay if they’re defended. (No canned answers, please; address the items from the list.) But I will not allow a direct link to the list of seven items under any circumstance. The site is a pro-circumcision fetish site, complete with circumcision fiction. I will not promote it. If you must visit it (NSFW), follow the link through NotStyro’s tweet above. Anyone may participate, of course. To NotStyro directly, I’m asking for more information.

On to item #1:

1. The foreskin increases the risk of male and female infections.

  • ‘Current new-born circumcision may be considered a preventative health measure analogous to immunisation in that side effects and complications are immediate and usually minor, but benefits accrue for a lifetime’

“May be considered” is a claim, not a fact. Nor is infant male circumcision analogous to immunization. The threats are distinct. Unvaccinated, I could catch measles by simply going out in public. I am not going to become HIV-positive without specific sexual behavior I can control, regardless of whether or not I have my foreskin.

There is a further complication to the comparison. The recent, actively-touted studies looked only at female-to-male HIV transmission. This is the least common transmission among those involving men. For example:

Female-to-male HIV infection was not observed in long term stable monogamous relationships. These results emphasize the relative uni-directionality of heterosexual transmission in non-promiscuous couples.

That suggests what we already know. HIV is transmitted through promiscuous, unprotected sex. Pretending that circumcision is a significant benefit when neither of those conditions exists is wishful thinking. Circumcised or not, if an individual behaves recklessly, there are consequences. That is the lesson. Parents will be more successful at keeping their sons (and daughters) safe from HIV if they teach them about responsible sexual behavior. No medical expert proposes that circumcised men may now ignore condoms. Circumcision is superfluous and unnecessary. This is particularly true in the United States, where HIV infections result primarily from IV drug use and male-to-male transmission. Circumcision is irrelevant to the former and ineffective to the latter.

The rest of the claim is questionable, as well. Minor complication is subjective, as determined by the victim. You may think a skin tag is “minor”; I would not. I prefer to think of complications as treatable and not treatable. In this case, yes, most complications are treatable. That raises the obvious ethical question of imposing surgical risk on a non-consenting, healthy individual, which I will save for another post in this series.

But what about those complications that are not treatable? These can be lesser problems such as tight, painful erections. If we move up the spectrum, we can discuss males who lose portions or all of their glans. Are we still in the territory of “minor”? What if we go to the extreme, death. It happens. I won’t pretend it happens often, but how many times may it happen before we suggest that maybe healthy boys dying from by-definition unnecessary surgery is unacceptable? The lack of medical need demands the answer be 0. It isn’t, which demonstrates that we do not rely on facts when circumcising healthy infant males.

Continuing from the list:

  • Circumcision reduces the risk of vaginal infections.

Probably, based on some of the studies I reviewed. If, of course, the results were properly controlled and the results are transferrable to industrialized nations. Maybe, maybe not, but I’ll concede the point for argument’s sake. This is a factual claim. So what?

The underlying issue here is the ethical flaw. It is unethical to alter a non-consenting individual’s body to reduce the risk that his future partners – if he is heterosexual – will suffer vaginal infections. That is a decision for him to make. He may include his female partners in the decision-making process. But that is within only his discretion. All else is a speculative guess. A speculative guess involving another’s healthy body is indefensible, even if his parents make the speculative guess.

To put it in perspective, a male can’t cause vaginal infections if we prohibit him from having sex with women. He can’t cause vaginal infections if we remove his entire penis. These are extreme, ridiculous hypotheticals. But they demonstrate that just because we can do something does not mean we should. There is more involved in permitting parental proxy decisions than just the fact that Action X generates Result Y.

Whether or not this generates a debate, and how long that debate transpires, will determine when part 2 appears. I will continue the series, regardless.

Is this a defensible thought-process?

I want to pass along an e-mail sent to David Wilson of Stop Infant Circumcision Society. There is rough language throughout, but it demonstrates a valuable point. [sic everywhere]:

I’ve seen the nasty ass excuse of a dick you rocket pop weilding bastards have I love my circumsized penis it is the prettiest dick I’ve ever laid my eyes on it doesn’t smell if I miss a shower either you sick fuck why would you want to inflict a circumcision on a full grown man any way have you seen the process fuck you my dick is gorgeous I love my wang and I sure as fuck wouldn’t of made the decision myself as an adult what kind of a fucked up world are you trying to create where an eighteen year old has to decide weather a mental scar like that is worth hygene

I am told that the choice to circumcise only male children for non-medical reasons is a parental right. This is objectively wrong, and this e-mailer is the too-typical anecdotal proof. I will posit that he is not qualified to make medically necessary decisions for a child, so medically unnecessary, permanent decisions should be prohibited. Despite this easy-to-understand truth, he is allowed to circumcise a male child with this thinking because no politician or judge has the courage to reject the status quo and defend the individual rights of all children. Our society is not yet sane on this topic.

Press Release: An Instrument of Distortion

I loosely follow a rule in my blogging that I don’t bother with press releases. They’re skewed to push the angle of whoever is paying the bill. It might be worth picking out the propaganda from a press release to find the facts, but I can usually achieve that with less effort by going to news sources to make a point. (Of course, most news sources reporting on circumcision are filled with propaganda, too.) Generally a press release is only good for demonstrating propaganda. This recent press release is a good example:

Hospitals in states where Medicaid does not pay for routine male circumcision are only about half as likely to perform the procedure, and this disparity could lead to an increased risk of HIV infection among lower-income children later in life, according to a UCLA AIDS Institute study.

The first half is fact. The second half is conjecture. News, then propaganda. The HIV-circumcision studies researched the effect of voluntary, adult male circumcision in reducing the risk of female-to-male HIV transmission from heterosexual intercourse. It is inaccurate to draw the conclusion that the foreskin puts men at higher risk of HIV. Unprotected sex with HIV-infected partners increases an individual’s risk of HIV infection. The male must first engage in that specific activity to become infected. Focusing on the foreskin distracts from efforts to reduce such behavior.

But that doesn’t sell the way fear sells.

But recent clinical trials in South Africa, Kenya and Uganda have revealed that male circumcision can reduce a man’s risk of becoming infected with HIV from a female partner by 55 to 76 percent. In June 2007, the AAP began reviewing its stance on the procedure.

By now you know what was left out of that summary, right? When public health officials talk about voluntary, adult male circumcision, they never mean voluntary, adult. Never.

As the press release so helpfully theorizes in its opening line:

Lack of coverage puts low-income children at higher risk of HIV infection

Think of the (poor) children. That’s not very original. It has the added bonus of being inaccurate. Are these children sexually active? Specifically for the age of the children discussed in this press release, the answer is no for 100% of them. They are not at risk of (female-to-male) sexually-transmitted HIV infection. But those necessary, contradictory details must be ignored. Think of the (poor) children.

That is how propaganda is done.

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Not to let an opportunity go to push for a collective response to an individual problem, the Family Planning Cooperative Purchasing Program helpfully regurgitates this press release, with the necessary bits of speculation helpfully emphasized in bold. An example:

In addition to the overall lower circumcision rates, the researchers found that the more Hispanics a hospital served, the fewer circumcisions the hospital performed. For Hispanic parents, the circumcision decision was about more than simply cost, since male Hispanic infants were unlikely to receive the procedure even in states in which it was fully covered by Medicaid.

What point is FPCPP trying to make with that emphasis, given the sentence that follows it? The only justification I infer is an implicit suggestion that we need to encourage Hispanics to “Americanize”. That wouldn’t surprise me because it’s the typical, mindless support for non-therapeutic genital mutilation in America. And FPCPP files this under “Public Policy”, among other categories. See above re: voluntary and adult. If it’s not that, I’m stumped.

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You and I, through a grant from the National Institute of Mental Health, paid for this research. Mental Health? With mission creep like that, who could possibly worry about government-run health care?

However, this raises the question of national health care and the future of routine infant male circumcision in America. I’ve long held that the former would not end the latter. The political environment for defending non-therapeutic circumcision is too strong, as evidenced by studies like the one leading to the above press release. No politician is going to say that parents can’t circumcise, despite the clear constitutional flaw in our status quo.

Ending public funding isn’t sufficient. The state should not pay for mutilation, but fails to end the practice. Poor parents pay for the surgery out-of-pocket. They complain about it, citing the potential benefits as an excuse for why Someone Else should pay, but they pay the cost anyway. Their sons are not protected by their state’s lack of Medicaid reimbursement. And ending government reimbursement doesn’t always end government reimbursement, as Minnesota’s politically-motivated solution showed.

Still, I need to have a think on my position. I won’t suddenly support government-run health care, but I should explore the nuances further.

Linkfest

LINK: Think government manipulation of intervention in the economy is good? Read George Will’s latest column. (H/t: Cafe Hayek)

LINK: Jim Harper has an entry on Cato @ Liberty discussing President Obama’s pledge to post all bills for 5 days of public comment before signing them. Mr. Harper reviews the steps the administration has taken and offers a positive review of the idea, although he correctly criticizes the administration for playing loosely with the 5 day timeline.

I agree with that in principle, but that’s not my concern here. The deficit spending bill mistakenly labeled The American Recovery and Reinvestment Act of 2009 is now online for public comment. I thought about adding comments, but why? I’m realistic enough to understand that what I say will not matter. It will not matter how many people comment against it, this is a done deal. The five days concept as implemented is worthless political propaganda. Honestly, if members of Congress can’t be bothered to read the bill, yet they’ll happily vote by party line, they don’t care what the American people think. They’re trading favors for power. The game hasn’t changed. So, wake me when this fails and tell me what the next stupid idea is.

LINK: I reject non-therapeutic infant circumcision because it is logically and ethically unacceptable. I question the science surrounding claims, particularly those involving HIV risk reduction, because there are obvious holes in the argument. However, unlike (too) many activists, I have no problem with vaccines. I think the logical and ethical arguments differ, and I don’t believe in conspiracy theories about Big Pharma. And from what I’ve read, the autism-vaccine link appears weak, at best. This report seems to confirm that (link via Kevin, MD):

THE doctor who sparked the scare over the safety of the MMR vaccine for children changed and misreported results in his research, creating the appearance of a possible link with autism, a Sunday Times investigation has found.

I would use this as a lesson for everyone who thinks that a claimed HIV risk reduction for (adult, voluntary) male circumcision need to be concerned about the long-term reality of their idea. I think we will eventually look back on the HIV-foreskin connection and realize the mistakes in the studies. But I do not approach the topic from that angle. I don’t need it, of course. I can concede the point for the argument and rely on ethics and objective indications of health and easier methods prevention.

For now, it’s too late anyway. The link has gained widespread acceptance because people want to believe it, regardless of facts or reasonable caution. The mindset is the same, as this excerpt from Orac’s post at Respectful Insolence suggests. (I read the post, but there’s too much to parse easily, so I’m using the summary pulled by Kevin, MD.)

“None of this will matter to antivaccinationists,” he writes, “who view Wakefield as . . . a persecuted scientific hero . . . I’m sure that [anti-vaccine proponents] will wax ridiculous about what a great doctor and man Wakefield is and how it’s big pharma and its minions who, frightened by the implications of Wakefield’s work, are working hard to demonize him and suppress his ‘science.'”

When emotion precedes logic in an objective debate, reason is lost. That would be unfortunate but defensible if it only affected the decision maker. It does not. The individual fears of parents results in poorly conceived decisions for children. Vaccinate but circumcise. Don’t vaccinate and don’t circumcise. Neither combination is justifiable when weighing the evidence with logic and ethics.

LINK: To lighten things up just a bit, will the Mets never learn?

“Whatever they did last year, they already got paid,” [Francisco] Rodriguez told the New York Daily News. Whatever they did, I have all the respect in the world. They worked hard and they deserve it. This is a different year and different ballclubs now. I don’t want to make any controversy, but with me and (J.J.) Putz and the additions in the bullpen, I feel like now we are the team to beat.”

K-Rod should ask Carlos Beltran how that worked out last year. However, I love this rivalry.

From the Archives: The Ethics of Vanity, Part III

The madness continues [emphasis added]:

About 150 patients in the U.K. have already received injections of Vavelta, a foreskin-derived skin treatment aimed at rejuvenating and smoothing skin withered with age or damaged by scarring from acne, burns and surgical incisions, according to a spokesperson for Intercytex, PLC, the Cambridge, England-based company that makes the product. The U.S. Food and Drug Administration (FDA) has not approved Vavelta, nor have any other federal agencies outside the U.K., where it was introduced in June 2007.
…

The fibroblasts in Vavelta are isolated from the foreskins taken from baby boys [ed. note: healthy baby boys], given several months to grow and multiply in the lab, and then packaged into treatment vials that are shipped to a select group of U.K. physicians. Each vial costs approximately 750 pounds, or $1,000], according to the company spokesperson.

I discussed Vavelta in November.

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Last week I saw news links similar to discussed before. And, while I’m happy an ethical issue appeared in the article…

There are also ethical issues to consider, especially if the folks behind Vavelta start paying parents for their sons’ severed sheaths.

… it hints at the wrong ethical issue. Parents do not own their sons’ foreskins. That’s why they don’t have the right to cut them off, much less demand payment for them. If a similar value worked for freshly circumcised adult foreskins, adult males should be free to sell for the highest price. They’re not, because the state thinks selling parts of your body is “wrong”. But taking healthy, functioning body parts from a child for no objective reason without his consent? That’s somehow a valid parental choice. It’s madness.

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There was more in the original post, but it’s not necessary to repeat for this. I’ll add that discarded foreskins from adult males do not work well for this procedure. That changes nothing surrounding the ethical argument that demands stopping this practice.

Australia Imports American Nonsense

Arguing in favor of circumcising male infant to reduce their risk of HIV infection is flawed thinking, even in places like Africa. It’s exceptionally ridiculous when looking at the extent to which pro-circumcision advocates bypass logic. From a recent Reader’s Digest Australia article on male circumcision, included in the section labeled “Verdict”, this quote:

“‘If it ain’t broke, don’t fix it’ is the understandable attitude of many Australians,” says [University of Melbourne] Professor Roger Short. Yet he questions this wisdom. “Australia is blessed with a low prevalence of HIV infection, but parents need to remember their children will encounter high rates in many countries they visit.”

How does he know male individuals will visit other countries? How does he know that those countries will have high rates of HIV infection? How does he know male individuals will have vaginal intercourse with HIV infected women? Where logic demands a different conclusion, Professor Short relies on propaganda. He began with his conclusion and grasped for assumptions to build around that to defend what is objectively indefensible.

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That’s unsurprising because the article is structured to reach one conclusion. Among the arguments offered in favor of circumcision, the article includes “Appearance”:

Research by Professor Marvel Williamson from the School of Nursing at Oklahoma City University found women prefer the look of a circumcised penis. “Generally women said it is more sexually appealing,” says Williamson. “Ninety per cent of women said it looks sexier and 85% said it’s nicer to touch.”

This is a non-medical argument used to excuse surgery on a non-consenting, healthy child. It’s also a subjective criterion that will be irrelevant to the 10% and 15% of women, respectively, who disagree with the majority. It will also be irrelevant if the male is gay. This conclusion also demands that we accept an external locus of control for all male sexuality. What the society wants matters more than what the individual wants for himself. Human rights belong to the individual, so we must reject all of this.

But look at what the article explicitly ignored. It’s obvious by the location of the research. A quick scan of the study reveals the omission.

This study clearly support the hypothesis that American women prefer circumcision for sexual reasons. The preference for circumcision does not necessarily come out of ignorance nor from lack of exposure to uncircumcised men.

Yeah, noting that the conclusion concerns American women might help Australian parents, except Australian statistics look nothing like American statistics in 2009. Also, this assumes that the mother’s preferences – or the father’s opinion about his own penis – matters. We’re not assuming that because it doesn’t matter. Professor Williamson incorrectly thinks it does, as shown in the design of her study:

Of 145 new mothers of sons responding to this survey, …

Are we really so stupid that a parent’s opinion on the sexual aesthetics of a child’s genitals is considered a valid reason for surgical alteration? I want to believe we are smarter, but the evidence is very clear that parents can and do use this excuse. That position is indefensible. Remember that all tastes and preferences are subjective, unique to each individual. The choice on whether or not to allow the subjective tastes and preferences of his future sexual partners to influence his decision regarding cultural, medically unnecessary circumcision must be left to him. Ethically, parents may offer proxy consent to circumcision only when medical need exists, and then only when less invasive solutions are insufficient.

An Imaginary Distinction

UNICEF is promoting efforts to end female genital mutilation. This is good. But I’m predictably distracted by the news release.

Female genital mutilation or cutting is the partial or total removal of the external genitalia – undertaken for cultural or other non-medical reasons – often causing severe pain and sometimes resulting in prolonged bleeding, infection, infertility and even death.

Male genital mutilation or cutting is the partial (and sometimes accidental total removal) of the external genitalia – undertaken for cultural or other non-medical reasons – often causing severe pain and sometimes resulting in prolonged bleeding, infection, and even death. I narrowed the reality of total removal and ommitted infertility. Neither of those changes is sufficient to introduce the gender bias that so many demand. Yet, that is exactly what organizations like UNICEF insist upon because (adult, voluntary) male circumcision may reduce the risk of female-to-male HIV transmission during unprotected intercourse. Despite its claims, chasing potential benefits is not a valid medical reason to circumcise non-consenting, healthy individuals – including male children.

John Harvey Kellogg’s Legacy

The “OMG Michael Phelps smoked marijuana” story is still a hot topic, with the general tone thankfully being that this is hardly worth wasting the effort of any brain cells. I concur, but that won’t stop the usual idiots from moralizing. The extends a little further to at least the appearance of moralizing, as evidenced by Kellogg dropping its endorsement deal with Mr. Phelps. I regard this as nothing more than a business decision. It’s weak and cowardly, but nothing in my support for capitalism suggests that individuals can’t be stupid.

Still, this provides a reminder that the company’s co-founder, John Harvey Kellogg, endorsed and promoted a radical, not-uncommon opinion for the late 19th century. From Kellogg’s book, Plain Facts for Old and Young, here is Kellogg’s “cure” for masturbation in children:

In younger children, with whom moral considerations will have no particular weight, other devices may be used. Bandaging the parts has been practiced with success. Tying the hands is also successful in some cases; but this will not always succeed, for they will often contrive to continue the habit in other ways, as by working the limbs, or lying upon the abdomen. Covering the organs with a cage has been practiced with entire success. A remedy which is almost always successful in small boys is circumcision, especially when there is any degree of phimosis. The operation should be performed by a surgeon without administering an anæsthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment, as it may well be in some cases. The soreness which continues for several weeks interrupts the practice, and if it had not previously become too firmly fixed, it may be forgotten and not resumed. If any attempt is made to watch the child, he should be so carefully surrounded by vigilance that he cannot possibly transgress without detection. If he is only partially watched, he soon learns to elude observation, and thus the effect is only to make him cunning in his vice.

This is one of the contributing arguments that encouraged the establishment of routine, medically unnecessary male circumcision in America. Anyone who denies this origin is misinformed when seeking a gender-based exception to the objective claim that medically unnecessary genital cutting on a non-consenting individual is unethical, whether the mutilated is female or male.

To demonstrate further, this is from Kellogg’s writing:

In females, the author has found the application of pure carbolic acid to the clitoris an excellent means of allaying the abnormal excitement, and preventing the recurrence of the practice in those whose will power has become so weakened that the patient is unable to exercise entire self-control.

Victorian-era Americans embraced circumcision because they replaced priests with doctors. They did not replace superstition with science. American medical knowledge of the foreskin accepted a religious foundation for any research, just as American medical knowledge today is ignorant of the foreskin because the circumcised penis is viewed as normal rather than common.

While I think boycotting Kellogg in 2009 because John Harvey Kellogg was despicable in 1888 is melodramatic, the history is worth repeating independent of the company. Boycotting Kellogg in 2009 because of it’s business decision regarding Mr. Phelps is a different matter. I support that.

Irrational Requests as Ethical Dilemma

Is it ethical to use fertility treatment when the mother already has six children?

How in the world does a woman with six children get a fertility doctor to help her have more _ eight more?

An ethical debate erupted Friday after it was learned that the Southern California woman who gave birth to octuplets this week had six children already.

Large multiple births “are presented on TV shows as a `Brady Bunch’ moment. They’re not,” fumed Arthur Caplan, bioethics chairman at the University of Pennsylvania. He noted the serious and sometimes lethal complications and crushing medical costs that often come with high-multiple births.

So I don’t use this solely to leapfrog to my concern, I’ll say no, it’s not ethical, although I won’t go so far as to say it should be prohibited. But if the facts are as they’re being speculated in the media, the doctor who administered these fertility treatments acted unethically.

Okay, so to jump to my question. We’re talking about whether this is ethical, but not enough people would realize the ethical dilemma this presents for the law. This woman can legally alter the genitals of six of her newborns, for whatever reason or no reason, while her other two newborns are legally protected from unnecessary genital surgery. The general consensus in the American medical and legal community is that this is ethical. No one should be surprised that a ridiculous case of fertility treatment for a woman with six kids can occur.

AIDS relief does not redefine moral behavior.

Although I largely ignore Michael Gerson’s columns because I know it’s going to be feel-good, big government social conservatism, I will defend him on one point from his column today defending ousted PEPFAR coordinator Dr. Mark Dybul and condemning the method of his ouster. Primarily, Gerson states:

A few radical “reproductive rights” groups — the fringe of a fringe — accused Dybul of advocating “abstinence only” programs in AIDS prevention. It was always a lie. Dybul consistently supported comprehensive prevention efforts that include abstinence, faithfulness and condom use — the approach that African governments themselves developed. …

I conducted a quick search to find proof on what I know about PEPFAR and found this quote from the New York Times, from December 14, 2006:

[Dr. Dybul] also warned that it was only one new weapon in the fight, adding, ”Prevention efforts must reinforce the A.B.C. approach — abstain, be faithful, and correct and consistent use of condoms.”

So Gerson’s point that Dr Dybul is being unfairly attacked on these grounds is accurate.

However, the “it” Dr. Dybul refers derives from the previous paragraph in the New York Times story, an angle I knew I’d find in my research.

Dr. Mark Dybul, executive director of President Bush’s $15 billion Emergency Plan for AIDS Relief, said in a statement that his agency ”will support implementation of safe medical male circumcision for H.I.V./AIDS prevention” if world health agencies recommend it.

From PEPFAR’s male circumcision brief, updated January 2009, here is a sample of PEPFAR’s work:

In Zambia, PEPFAR continues to support a broad approach to prevention which includes male circumcision. Safe and effective medical male circumcision services are now provided at various sites to reduce new HIV infections and other sexually transmitted diseases. Working with the Ministry of Health, male circumcision is offered at the University Teaching Hospital in Lusaka and the General Hospital in Livingstone, as well as through satellite facilities. PEPFAR is also supporting training, public health evaluation on neonatal circumcision, and the development of comprehensive prevention messages to accompany medical male circumcision services. [emphasis added]

This is an action overseen by an individual Gerson describes as “a great humanitarian physician — a man of faith and conscience”. I have no reason to question the second claim, but one and three are demonstrably false.

I do not expect anything better from the Obama administration’s eventual pick to replace Dr. Dybul. Always remember that when public health officials talk about voluntary, adult male circumcision, they never mean voluntary, adult. Never.