ACCUMULATING PERIPHERALS


The foreskin police by mattsteinglass
August 27, 2009, 11:36 am
Filed under: Uncategorized

Easily the most amusing and hysterical reaction to the news that the CDC may recommend circumcision because it helps prevent AIDS came from the Daily Dish reader who wrote in:

It’s my dick. It’s my dick. It’s my dick. It is no one else’s dick but my dick.  And I should have the choice to circumcise it when I am old enough to make that decision.

Let me reassure this guy: no one is planning to do anything to his dick. Assuming, that is, that he is more than 8 days old. But with respect to the practice of circumcision, the important point is this: he’s my son. Not yours. Parents have the right to decide on medical treatment for their children, presuming such medical treatment is not actively harmful. And parents have the right to include their children in cultural rites and practices, again presuming no harm is done.

In the case of circumcision, the evidence shows that it prevents the transmission of HIV and other STDs. There is some disputed evidence, on the other hand, that it reduces sexual pleasure; and there are some ludicrous and hysterical people claiming that it damages the bond between mother and child. This certainly sounds plausible; we all know Jewish men don’t enjoy sex, and have trouble bonding with their mothers. Not.

What, then, of female circumcision? Well, I understand, perhaps wrongly, that there are some forms which are not particularly medically invasive, and which do not entail significant medical consequences. I think that such forms of female circumcision are a matter of cultural practice that should be left up to parents to decide. The more invasive forms of female circumcision entail serious negative medical consequences. Obviously that’s not cool. And female circumcision is carried out on girls aged 7 to 12 or even older; at that age, the child gets a vote, too. In any case, this doesn’t have much to do with anything, because we’re talking about a medical recommendation.

But the main point is that if the guy who wrote the email were circumcised, he wouldn’t have written the email. Men who are circumcised don’t complain about it. There may be some vanishingly small number of guys who are upset about the fact that their parents circumcised them. It’s a weird thing to be upset about. The whole issue of treating this as some kind of mutilation of a rights-endowed human being who should be allowed to decide for himself seems to me like an insane metastasis of the American fixation with individual rights-based ideology. Children are born into families. Those families have cultures and beliefs, and are entitled to make decisions about how their children will be treated, shaped, and raised.

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[…] Matt Steinglass: But with respect to the practice of circumcision, the important point is this: he’s my son. Not yours. Parents have the right to decide on medical treatment for their children, presuming such medical treatment is not actively harmful. And parents have the right to include their children in cultural rites and practices, again presuming no harm is done. […]

Pingback by A Sensitive Subject… A Very Sensitive Subject « Around The Sphere

This is a frustrating issue for a number of reasons. The first is that, as you have demonstrated yourself here, it’s difficult for anyone attempting to argue against the American norm of routine circumcision without being labeled a loon.

Well, I’m not a loon. I am someone who has educated himself about the issue. And that’s clearly something that you have not done. That’s another frustrating aspect of this discussion.

First of all, as I have been discussing at length at the League of Ordinary Gentlemen, the demographic that receives a benefit from circumcision, heterosexual men, does not contract HIV from sexual contact outside of sub-Saharan Africa. This is a fact that has been obscured by a well-intentioned, politically correct AIDS awareness movement, but it is a fact. In the developed world, HIV and AIDS are diseases restricted to those two populations. This is important for this issue, because each of these studies has confirmed that while circumcision lowers the risk of infection for female to male transmission for heterosexual males, there is no similar reduction in rates of infection for homosexuals or for woman from male to female infection. In other words, the people who would receive a benefit from circumcision are people who do not contract HIV outside of sub-Saharan Africa.

Why? Because sub-Saharan Africa has unique cultural and logistical circumstances that make HIV infection from heterosexual sex likely, whereas such infection is almost entirely unheard of in other parts of the world. Specifically, a cultural preference for artificially dry sex that is found only in sub-Saharan Africa, and the social acceptance of ulcerative sores on genitalia from other sexually transmitted diseases in sexual partners. HIV is reliably transferred only through blood to blood contact. Such contact is common in homosexual sex due to microabrasion, common in the sharing of intravenous needles, but very rare outside of sub-Saharan Africa.

I highly recommend James Chin’s book “The AIDS Pandemic”. Chin is no zealot; he’s an epidemiologist with 50 years of experience who was at the very beginnings of the American AIDS epidemic in southern California, saw the disease spread and saw the politicization of the AIDS movement. He wrote his book in response to flatly incorrect information about the prevalence of AIDS worldwide, and misinformation about who contracts the disorder.

Personally, I find circumcision for men in sub-Saharan Africa to be a great tool for use in combating AIDS in a place where it genuinely represents a pandemic. And I further support, of course, the rights of parents to circumcise their children for religious or cultural grounds.

But I don’t support a recommendation for routine circumcision in the United States, because the United States rate of HIV infection is incredibly small, and because the populations who are infected are exactly the populations who are not protected by circumcision. That’s the issue here, the medical issue, and as the number of people infected with HIV are one third of our population, and as the vast majority of those receive no benefit for circumcision, I don’t support a routine infant surgical procedure for an entire gender.

Now I ask you: do you think I’m a zealot or a crazy? You know this is one of the most disrespectful posts I’ve read in a long time, and it’s also a deeply uninformed post. You move the goalposts, too, changing the argument from one about a medical necessity to one about parental rights and religion. No one is advocating that parents shouldn’t have the right to choose. And no one is saying that people shouldn’t be able to practice their religious customs. But the medical case for routine circumcision is incredibly slim, and in fact not supported by the studies that have shown the advantage of routine circumcision in sub-Saharan Africa. That’s what is being discussed here. I’d like it if you could engage in the discussion with more than your obviously cursory understanding of the issue, and without knee jerk assumptions that anyone doubting the medical necessity of the procedure is some sort of zealot.

Comment by freddiedeboer

Freddie: I already knew everything you wrote in your post. I have known most of it for 7 years, since I lived in Africa.

The basic problem is that you’re wrong when you write “No one is advocating that parents shouldn’t have the right to choose.” That’s not true. There is a rights-based argument circulating that parents don’t have the right to impose their cultural or medical judgment on their infant children by circumcising their sons. There are organizations devoted to this position. And it is that small subset of people who argue this case that I have a problem with. I don’t have a problem with people who argue that the epidemiological case for circumcision in the US is not strong enough to merit a default recommendation. I disagree narrowly, but I don’t have a problem with the argument, and it seems to me like a very arguable case. You should, incidentally, take into account the fact that circumcision also helps prevent HPV and herpes infection.

But you seem not to have read my post very carefully. The guy I was responding to was making the claim that because he, as an adult, wishes he had not been circumcised, parents do not have the right to circumcise their kids. That’s a pretty invasive argument to make, and one I strongly doubt you’d be willing to get behind. I did not say that it was ridiculous to oppose the CDC recommendation on the grounds that the epidemiological gains in the US are not significant enough to outweigh other alleged harms. That’s a reasonable argument; I disagree, but I think it’s up to the docs to decide.

Comment by Matt Steinglass

One other thing: this moves onto a largely separate topic, but one of the problems as the issue of HIV prevention moves forward in the US is that if you restrict the prevention strategies to the populations that are really at risk, you’re pretty much talking about blacks, hispanics and gays. Especially blacks. Close to 50% of new infections are in blacks, and the populations with really runaway infection rates are places like DC, where if I understand it correctly the prevalence may have hit 10%, which is a level unseen outside of subsaharan Africa and Haiti. Overall prevalence among blacks is about 2%, which is less than Thailand but more than India, and still plenty enough to be considered “epidemic”. If you’re going to start restricting your prevention recommendations to the populations that are actually statistically at risk, those prevention strategies may start looking pretty racist. For instance, infection rates among black women are high enough at this point that you may, in that population, be looking at significant female-to-male sexual transmission, especially as there’s some evidence that black rates are higher because of sexual self-segregation. But it’s obviously a no-go to recommend that only black males wear condoms, say, because white males run no significant risk of HIV infection through heterosexual sex. But this is a just a side issue related to the approach of confining public health recommendations to particular subgroups that are affected, and it’s to some extent an unavoidable issue — public health strategies really do need to be tailored to different populations, and you just need to find ways to get around or assuage those political sensitivities somehow.

Comment by Matt Steinglass

Freddie, Freddie… my poor dear delusional Freddie,

One can write a 10,000 word exposition, but if an initial assumption is fallacious, the rest all washes straight down the drain. Now what did you say again?

“heterosexual men, [do] not contract HIV from sexual contact outside of sub-Saharan Africa.”

Given my 15 or so practicing years as a gay man, let me clue you in pal: If you knew just how many men live their entire lives pulling the blinds over their families’ eyes, and sneaking out to the bathouse for some gay strange, you might be in for quite a shock.

Case in point, i do have childhood recollection of being in church (ca. 1984) and one of the family men there contracted what was accepted to be some obscure illness that caused him to waste away, and eventually die. Family man, wife, 2 kids. Mom told me some years later it was AIDS, and it finally made sense.

So, hopefully, you will temper your crusade with a little more real world common sense. A label like ‘heterosexual’ is only as accurate as the faith you can have in a human being to always tell the truth. And as someone who knows, let me tell you that human beings lie their asses off every day.

Comment by andygeiger

A fairly self-serving article (and yes, I’m making some assumptions as to the origins of the name Steinglass) that cites to health reasons to justify “cultural traditions,” without any real discussion of the underlying issues or propriety of those traditions.

The fact remains, though, that almost no one who was not circumcised as a child would elect to have that procedure done as an adult. Therefore, per the Golden Rule, I think that, absent compelling health reasons, which other commentors have sufficiently exposed as dubious (at least outside sub-Saharan Africa), there is no justification for the practice.

Comment by wybz

*The fact remains, though, that almost no one who WAS circumcised as a child would elect to have that procedure REVERSED as an adult. Therefore, per the Golden Rule, I think that, absent compelling health reasons, which other commentors have sufficiently exposed as dubious, there is no justification for refraining from circumcising children.*

See the problem? You’re talking about identity formation. A very small number of adults who aren’t circumcised want to get circumcised. A very small number of adults who were circumcised wish they weren’t. Basically, the way you get formed is who you are. About as many people are going to resent their parents for (not) circumcising them as will resent their parents for bringing them up speaking Spanish or not breast-feeding them. These decisions are made by families. Families have the right to make them. The responsible thing to do is to present the medical evidence, and leave it up to parents.

Comment by Matt Steinglass

Really?

Well, at least you’re not wasting your time with Megan McArdle anymore.

Comment by Mish

So what is the downside of being circumcised? Pain? Women laugh at you? Neo Nazies call you a jew? Anger towards your parents? When I was born it was the law. I have no idea why. Some guy told me I’d be bigger if it didn’t happen…for a few minutes I wanted to sue New Jersey. Really is this really a major issue in a guy’s life?

Comment by libtree09

“… mutilation of a rights-endowed human being who should be allowed to decide for himself seems to me like an insane metastasis of the American fixation with individual rights-based ideology.”

You wrote that parents may circumcise their sons “presuming no harm is done.” You are making a rights-based argument that centers on the child possessing an individual right to be free from unnecessary harm. According to you, there are limits to how much culture may play a role. This makes the role and influence of the family and culture irrelevant here as the initial test; your claim hinges first on the merits of circumcision as surgery on a healthy child.

Circumcision is surgery. It removes healthy, functioning tissue. There is scarring. There is an inherent risk of further complications, starting with “excessive” bleeding and infection and extending all the way to death. The more extreme complications are, of course, rare, but the risk itself is a form of harm. Parents cannot know if their son will be the statistic. Good intentions are not a substitute for objective criteria. Using objective criteria, surgical intervention on healthy body parts is harm. Prophylactic and cultural child circumcision fails that test, which prevents moving to cultural considerations as a defense. Proxy consent is valid only where medical treatment is indicated (i.e. necessary). Parents do not have a right to impose medical treatment – in this case, surgery – because they like that medical treatment, for whatever reason they value it. This is precisely because it causes harm, the test you (correctly) established.

I suspect we disagree on whether or not circumcision is objective harm. But you didn’t attempt a defense of circumcision on that claim, the core of your dismissal. Instead, you essentially propose that subjective preferences are valid for parental decisions as long as the parents (and possibly a majority of society) believe them to be culturally valid and not harmful. That’s incorrect.

Comment by rollingdoughnut

If there were no cultural component in favor of this surgery, the prophylactic argument would never advance an inch. I’d say the argument is about 97% cultural and 3% prophylactic. In a world where circumcision was nonexistent, it wouldn’t be invented to solve the STD problem.

The medical benefits of circumcision are statistically insignificant, or at least only significant in specialized populations. Other remedies would achieve better gains without the harm of surgery — condoms, education, familial/cultural guidance.

I know the following is a fantastic, hyperbolic argument, but we could prophylactic-ally give all female children mastectomies and end the scourge of breast cancer. We’d have to wrestle with the same questions about surgical harm, sexual pleasure, personal body image, etc. How many of those women would miss the breasts they never knew? Especially if mass culture depicted a breasted woman as an anomaly, as the uncircumcised penis is?

Comment by acurry

No, I didn’t say the criterion of doing no harm is prior to the parental choice criterion. They’re simultaneous criteria. We don’t bar parents from piercing their kids’ ears. You meanwhile presume that cultural factors, parental preference and the medical community’s consensus on medical risk should have no weight at all. If circumcision lowers the risk of contracting HIV through heterosexual intercourse by 50%, the HIV+ rate in the US is 0.6%, and the percentage of those who contracted HIV through heterosexual intercourse is just 5%, then one might say that 12 in 100,000 American men have contracted HIV in a fashion that might be prevented by circumcision. That’s 18,000 men in the US. If the ratio established in Africa holds, one might expect to find that the ratio of circumcised men among those who contracted HIV through heterosexual sex in the US is not the 70% found in the population at large, but significantly lower, more like 50%. And that if all of the uncircumcised 50% had been circumcised, half of them would not be HIV+. The guesstimate yields about 4,500 men in the US who would not be HIV+ if they had been circumcised. For comparison, what is the incidence of complications due to circumcision, and how serious are they, in comparison to contracting HIV? This is the way to consider whether or not to make a recommendation on medical grounds.

Comment by Matt Steinglass

My point is that without the cultural foot-in-the-door, circumcision would never be considered as a means to prevent a mere 4500 infections. Don’t get me wrong, one is too many. There is an ethical calculus one must undertake in order to instigate the kind of mass surgical intervention that routine circumcision has become. Cultural influences have made an end-run around that kind of ethical debate.

One might also evaluate education and increased use of condoms using similar calculations. The difference, of course, is that there is zero risk of physical harm in education. How many infections were helped along by the Pope proscribing the usage of condoms?

Did it appear that there were any socioeconomic or cultural factors accounted for in the study? If not, I would think you’d have plenty of room for correlative error along cultural and socioeconomic lines.

Comment by acurry

“… Parents have the right to decide on medical treatment for their children, presuming such medical treatment is not actively harmful. And parents have the right to include their children in cultural rites and practices, again presuming no harm is done.”

How should I read that, if not as placing the criterion of no harm to the child before the criteria of parental preference and potential benefits.

You’re correct that I presume that cultural factors, parental preference and the medical community’s consensus on medical risk should have no weight at all, but I specifically add the condition that the person being circumcised is healthy and can’t consent. That obviously includes children. He may not value those factors in the same subjective way as the others involved. I don’t value them the same as my parents, the doctor they chose, or many of my fellow citizens. And circumcision causes harm, as I stated in my last comment. It meets my test for prohibiting parents from making the decision. Again, I think it meets the test you established, as well.

The (subjective) cost-benefit discussion of HIV is a distraction from the primary test you established. It should be involved, I suppose, but not until the other questions have been addressed first. The problem is that you’re taking the science of a study conducted with adult volunteers as a substitute for the ethics of cultural circumcision of infants. Why is it unreasonable to expect circumcision in America as an HIV-risk reduction method to involve adult volunteers rather than children? If circumcision is useful, the arguments for choosing circumcision should be powerful enough to convince adult males to voluntarily undergo the procedure.

The only opinion you’re ignoring in your analysis is the person being circumcised. Even the reasonably objective consensus on medical risk and benefits is still subjective in its application to each patient. (Let’s not forget the medical consensus on the objective health of newborn foreskins, which is also scientific.) We can talk about complication rates versus risk reductions but there are males who constitute those statistics. Why shouldn’t their opinions matter before the unnecessary surgery rather than after when they must deal with the outcomes? They can take actions to prevent the diseases. They can’t take actions to prevent the complications.

To your HIV example, this utilitarian evaluation should include the tens of millions of American males circumcised at birth to achieve an HIV+ rate in America that is higher than every other Western nation. Most of those countries don’t have anywhere near 10% of males circumcised since before the rise of HIV. Why is our HIV+ rate higher? It’s reasonable to posit that lack of circumcision is not the problem.

More importantly, those 4,500 men would not be HIV+ if they hadn’t engaged in unsafe sex. Their foreskin isn’t the cause of infection. They didn’t deserve HIV because they didn’t use condoms, of course, but their unfortunate reality doesn’t permit us to dismiss the rights of their male peers upon birth, peers who will mostly be responsible or at very low risk.

Comment by rollingdoughnut

You say men who are cut don’t complain about it, but over 200,000 men are enduring a tedious multi-year process of non-surgical foreskin restoration to get back a measure of the pleasure-receptivity that was taken.

You say it’s a medical decision parents can make, but infant circumcision is not endorsed by any national medical association of doctors anywhere on earth – not even Israel’s. The cost of American juvenille corrective surgeries and other circumcision re-dos matches the total cost of 1.3 million infant procedures allowed in the US each year.

You mention HIV, but infants aren’t at risk for sexually transmitted infections. If they were, infant condoms would be the most effective and cost-effective means of prevention, just as in adults. Most of the US men who have died of AIDS were circumcised at birth. The US has a mostly-cut adult population and THREE TIMES the HIV incidence that Europe has, even though circumcision is very rare Europe. You should also know that the Africa researchers announced this summer that the HIV+ men they circumcised were 50% MORE LIKELY to transmit HIV to a monogamous partner than the HIV+ men they left intact were.

All males can decide at a rational fully-informed age whether to use a condom and other safer sex measures, or trust in a pleasure-reducing amputation to fight HIV. If he does choose circumcision then, he’ll get real pain management, less risk, a more precise cut, healing that’s not in a fouled diaper, and some say in the style of the result.

Comment by tlctugger

[…] by Freddie at The League of Ordinary Gentlemen in which he completely eviscerates a Matt Steinglass post on circumcision.  Putting aside the substance, it’s a great explanation of how not to write […]

Pingback by The Cruelty of Circumcision | ThePolitic.com

There, indeed, is a right to bodily integrity. Although it may seem silly to you, the courts in Oregon recently protected a boy from a circumcision his father wanted, but he did not want.

One should note that circumcised men, who have lost some much sensory tissue, from their penis have an acute emotional need to minimize that loss. When they can no longer minimize the loss, they seek to justify it by citing illusory medical benefits.

Comment by macuser




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