Dialog on AAP's new Female Genital Cutting policy

The American Academy of Pediatrics has released it's Policy Statement on Ritual Genital Cutting of Female Minors. What little response I've seen to it thus far has come from individuals and groups which take a position on some or all medically unnecessary genital cutting on children. The response indicates controversy over the policy.

I have a lot of thoughts on this which I haven't fully sorted out. I intend to write several blog posts about it, and your comments will help shape the direction of the discussion.

Exemplifying the controversial statements in the policy is the following:

Most forms of FGC are decidedly harmful, and pediatricians should decline to perform them, even in the absence of any legal constraints. However, the ritual nick suggested by some pediatricians is not physically harmful and is much less extensive than routine newborn male genital cutting.

This statement troubles those who take a zero tolerance view of applying sharp objects to the genitals of children without medical necessity. It also seriously disturbs individuals and groups who would build a "wall of separation" between male and female genital cutting practices and find any comparison between male and female genital cutting to be offensive.

Here are some of my initial thoughts and questions.

Why has the AAP issued a policy statement on FGC at all? The practice is forbidden by law in the United States, which is the only nation they represent.

Is this news reported by Equality Now really just a random coincidence?

On 26 April 2010, ironically on the same date as the issuance of the AAP Statement, the United States Congress introduced new legislation amending the 1996 federal law prohibiting FGM to make it illegal to transport girls out of the country for purposes of FGM, also known as the “vacation provision.”

Will the sponsor and co-sponsor of the "vacation provision" amendment, Rep. Joseph Crowley (D-NY) and Rep. Mary Bono Mack (R - CA), also introduce MGMBill, which not only extends protection to American girls outside the borders of the United States but also extends protection to boys?

Does this policy signal anything about the stance the AAP will take on genital cutting of male minors when they release their policy on it?

Circumcision may increase HIV spread among gay men

We need data, not headline.

It's unconscionable that since early today, this story has been all the public knows about the referenced study.

Here is what little we are told:

"The findings are based on data from 4,889 men who took part in an HIV vaccine trial begun in 1998; 86 percent had been circumcised. During the three-year study, 7 percent of the men became HIV-positive.

When the researchers accounted for other factors -- including demographics, and HIV risk factors like drug use and having unprotected sex -- circumcision showed no effect on the odds of HIV transmission.

Still, Gust and her colleagues point to some limitations of their study, including the relatively small number of uncircumcised men overall and the small number of uncircumcised men who became HIV-positive during the study -- 43"

So, what can the public think with so little to go on?

4,889 men

86% circumcised

7% HIV infection rate

43 intact men became HIV infected

So that means:

4205 circumcised men (4,889 * .86) = 4,205

684 intact men (4,889 - 4,205) = 684

342 men infected (4,889 * .07) = 342

43 intact men infected

299 circumcised men infected (342 - 43) = 299

7.11% circumcised men infection rate (299 / 4205) = .0711

6.29% intact men infection rate (43 / 684) = .0629

Well, isn't that curious. If you stop and puzzle it out, assuming what little data we're given is at least accurate, you find circumcised men had a 13% increase in HIV infection.

13% increased infection rate of circumcised group (.0711 - .0629) / .0629 = .1304

But it's time-consuming and inconvenient to see this fact. In other words, it was spun to favor the hypothesis of the researchers. The same hypothesis which this data resoundingly fails to confirm.

Since the reporters chose a headline expressed as "circumcision (or not) may (or may not) cut (or not cut, or increase) HIV spread among gay men," it would be more in agreement with the study if the headline were "Circumcision may increase HIV spread among gay men."

If that sounds like an overly strong and misleading title, consider that the actual title ("Circumcision may not cut HIV among gay men") must then be more overly strong and misleading, since it is less true to the data.

The first paragraph of the article establishes relative risk reduction as the standard for this sort of study:

"A number of studies in African nations have found that circumcised heterosexual men were up to 60 percent less likely than uncircumcised men to contract HIV during the study periods."

Given the researcher bias in favor of the hypothesis, and the use of relative risk reduction figures for past studies, does anyone think this wouldn't have been expressed as a 13% reduction in HIV, though statistically insignificant, if it had been in favor of the circumcised group?

We are being spun by the researchers (*) while the data is withheld from the public.

(*) The reporters are not making things better.

No evidence circumcision works = It may work?

It's natural to seize any possible hope for slowing or stopping the spread of HIV. Some researchers have spent careers investigating the hypothesis that less penis will lead to less HIV. But even when evidence emerges that this hypothesis is wrong, it is spun as hope that it may still be right.

Today it is reported that in the latest study of 4,889 homosexual men, about 7% became infected with HIV over three years, regardless of whether they were missing part of their penis.

circumcised and uncircumcised men showed no difference in the risk of HIV infection over three years.

while having unprotected sex with an HIV-positive partner increased a man's risk of infection, there was no evidence that circumcision altered that risk.

The report also makes clear that no previous studies have found circumcision helpful in preventing HIV in gay men, either:

There has so far been no good evidence that circumcision lowers HIV risk among these men.

Despite all the speculation, hope, and expense aimed at discovering that it does, there is no evidence that reducing the penis also reduces HIV infection. There is, however, good evidence that it does not.

But those looking for such a link still have hope. If only they could receive more funding, and perform larger studies, perhaps they may find that if gay men only had their foreskins removed, they might get less HIV.

This hope can be seen in the language in the story, which reflects the views of the researchers who would like more funding to perform more studies. Let's compare what is actually known with what is stated:

evidence that circumcision does nothing --> "may not do much"

evidence that circumcision clearly did not help --> "unclear"

circumcision made no difference --> "may not make much difference"

Is this simply the sort of sensible caution which should always be applied to medical study results? If so, we would expect the same caution to be applied to the evidence which found reduced HIV transmission to heterosexual adult men in Africa. Those findings should be similarly stated with prudent scientific uncertainty. Let's see what the same article says about those studies:

A number of studies in African nations have found that circumcised heterosexual men were up to 60 percent less likely than uncircumcised men to contract HIV during the study periods.

Nope. It's not even-handed caution. Evidence which favors circumcision is stated as a fact. Despite weaknesses in those studies, there's no hedging whatsoever. No admission that they could be wrong. No call for further evidence. But when evidence emerges that circumcision is useless, the headline tells us it still may work, and the researchers tell us it needs more study.

future studies, with larger samples of uncircumcised men, should continue to look at the question of circumcision and HIV transmission among men who have sex with men.

I'm just going to come out and say it. Some of these researchers have a cultural bias. They favor circumcision for reasons unrelated to HIV prevention, and they want more funding to study circumcision. Some of the reporters, too, are culturally biased to accept information favorable to circumcision.

Let's get something straight

Opinions fly every day and from every angle on circumcision. Not the kind of circumcision people choose for themselves. Not the kind so medically necessary that any other body part in similar condition would need to be amputated. The kind physicians routinely ask "we doin' this?" and accept the answer "yes," no questions asked. The kind parents elect for children, for any reason they bloody well please, or no reason at all.

You might think the status quo, as such, has some inherent validity, or at least is constitutional, but that is not always so. Not just the U.S. constitution, but the natural law on which the United States is, substantially, constituted. The people are not "secure in their persons" if their body parts may be seized. We do not have "equal protection of the laws" when removing parts of the genitals of minors is prohibited for one, but not all sexes.

That circumcision was institutionalized in the United States does not, in itself, grant it any legitimacy. Examples abound, but rather than cite them, suffice to say that from time to time it becomes apparent that the status quo conflicts with our most dearly held principles. Non-therapeutic circumcision of children, an abridgment of the freedoms to which we are each entitled, is now so apparent. Although some may be employed, no new law or principle is absolutely needed for this error to be corrected. We need only stop making exceptions to those we already have.

Let's get something straight.

Freedom from non-therapeutic circumcision for everybody isn't just good policy. It's a self-evident right.

Sign a Petition

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#i2 is what, exactly?

The #i2 campaign for freedom from non-therapeutic circumcision is thriving on twitter. To date more than 15,000 tweets bear the #i2 tag. For both participants and bystanders, it's fair to ask, what exactly is #i2? Here's my take on it. Yours may be different.

• #i2 is a call for greater freedom
• #i2 is a statement of the rights of each individual
• #i2 represents everybody's individual right to keep their intact genitals
• #i2 asserts the standard of care for healthy newborn boys contra-indicates non-therapeutic circumcision

#i2 represents all these things and many more.

But most importantly, #i2 is tweeted by an ever-expanding number of users who have their own specific meaning for it.

• #i2 may mean you regret the poor information which led you to allow circumcision of your child
• #i2 may mean you know your right to keep your own body intact was violated
• #i2 may mean equal rights for males and females to unmodified sex organs

The "freedomfromcircumcision" twitter list is just about full. The maximum number of users on one list is 500. Soon, new users tweeting #i2 in support of the campaign will be placed on the "freedomfromcircumcision-2" list.

There are vast numbers of Americans who have not fully vetted these ideas. They are familiar with circumcision as something common in their culture, but have never confronted many of the facts or the idea that it's an improper imposition of parental will on the body of a child.

Many of them, along with those who already support these ideas, will eventually declare their support for #i2 after seeing the facts and argumnents put forward.

Every #i2 tweet is an opportunity to share this information with our friends, family, followers, and people we've never met.

Each of us who supports #i2 is a step on the path to securing freedom from non-therapeutic circumcision for everybody.

When, exactly, did Scientific American become Circumcised Americans Magazine?

Is Scientific American exhibiting the sort of bias found generally in American culture regarding circumcision?

First they bought hook-line-and-sinker a new boogeyman, "anaerobic bacteria." More of one class of bacteria (and less of another) became a preventative for HIV with nothing more than an amputative genital surgery, motivated speculation (1), and a gentlemen's agreement to never test or imagine such a hypothesis for females (to whom HIV is equally deadly).

Science shows the most sensitive parts of the genitals are removed by circumcision (Sorrells, et al.). Still waiting for that article.

And now, another data point. Circumcised Americans Magazine writes up a "cost-effectiveness" study concluding that a small African country can circumcise more people for the same money (and, allegedly, ultimately reduce HIV) if they target people who can neither volunteer nor refuse, and on whom the intervention has not been studied: newborns. So much cheaper would newborn circumcisions be, in fact, that the sexually active adults who would (again, allegedly) die of AIDS because they're left intact are acceptable casualties. Why does SciAm fail to note that these models rely on the untested and unproven speculation that newborn circumcision will impact future adult HIV rates? Where is the critical thinking? Where is the science?

This paper reports no hard science. It advocates policy based on economics using speculative models. Despite its policy advocacy, there is no mention of ethics or consent. An accompanying paper, which likens those who question the ethics of removing body parts from non-consenting children to "antiscience and antimedicine extremists" ignores all ethical concerns, too. Circumcised Americans Magazine plays along (just the science, M'am), pretending there are no ethical issues whatsoever.

Scientific Canadian of British Columbia just rejected the idea that this data means their newborns should be circumcised. Scientific Australian is entirely unconvinced newborns under their purview can avoid HIV by having this surgery. Both statements consider the ethical implications extensively. Scientific Brit, Scientific Frenchman, Scientific Swede, Scientific Dane, and Scientific Netherlander all do not believe circumcising their newborns makes any sense after reviewing this data. That is, if the physicians groups in all these countries can be relied upon to review the scientific evidence (as the American Academy of Pediatrics seems poised to do for Americans).

But Scientific American, hailing from the land of modified penises, staffed (one could reasonably guess) predominately by non-intact men (and those who know and love non-intact men) is quite intrigued by the idea of circumcision, at any age, in any place where the dispassionate science shall lead!

Onward, Scientific American! Let microbes which fare better in dry circumcised penises thrive, and let there be no safe quarter for those "oxygen hating" menaces which prefer intact male (and presumably female) anatomy!

Onward, Circumcised Americans! Let no lack of data on newborn circumcision keep us from the tiny, ethically neutral steps from adult volunteers in Africa, to non-adult non-volunteers in Africa, to non-adult non-volunteers in non-Africa (like most American Circumcisees!)

And remember: Observational facts like much higher rates of both circumcision and HIV in Americans, versus much lower rates of both circumcision and HIV in Europeans may be discarded because they are not randomized trials.

And the randomized trials? Don't forget, the stated conclusions of the American researchers who conducted them are so beyond doubt that they can never, ever, ethically be replicated! Not in Africa, and certainly not in the United States! Even if it were ethical, there simply is NO TIME to wait for adult outcomes to newborn circumcisions!

Scientific American? I'd like to believe that. But when it comes to circumcision, where is the evidence?

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(1) Guus Roeselers calls it "merely a causation hypothesis that was not experimentally addressed in this study."

Dr. Amy Tuteur's cloudy view of newborn circumcision

In her blog post The case for neonatal circumcision Dr. Amy Tuteur lashes out at those calling for freedom from non-therapeutic circumcision and displays a culturally biased view while advising the AAP to recommend the surgery for all newborn males.

Joining with Tobian, Gray, and Quinn she discards the careful consideration of physicians around the world who have consisently and recently rejected the arguments they are promoting.

Statement by the College of Physicians and Surgeons of British Columbia

Current consensus of medical opinion, including that of the Canadian and American Paediatric Societies and the American Urological Society, is that there is insufficient evidence that these benefits outweigh the potential risks. That is, routine infant male circumcision, i.e. routine removal of normal tissue in a healthy infant, is not recommended.

Statement by the Royal Australian College of Physicians (RACP)

“the RACP does not recommend that routine circumcision in infancy be performed.”

These statements were published in August and September of 2009.

In addition to recognizing the clinical data is insufficient to indicate newborn circumcision, and unlike Dr. Tuteur, these medical organizations give significant weight to the ethical issues involved in a surgery which is irreversible, unnecessary, and occurs without consent of the patient.

Dr. Tuteur uses sloppy language to make her case, for example by claiming "the benefits of circumcision are real and clinically important." In fact, they are only potential benefits which will not materialize, and will not be important for the vast majority of circumcised males. The risks of circumcision are also real and clinically important, but she omits them.

Is data from adult Africans any more applicable to American newborns than to Canadain, Australian, or British newborns? Probably not. The low rate of acceptance and support of newborn circumcision by physicians outside the United States, and relatively high rate of support among American physicians like Dr. Tuteur suggests that the existing culture of male circumcision here is clouding her view of the data, and completely obscuring her view of ethical considerations.

The early days of 2010 have seen a concerted effort by some to upset the trend of falling circumcision rates in the United States. The AAP appears likely to issue a revised recommendation on newborn circumcision in the near future. Hopefully they will avoid the cultural bias which affects Dr. Tuteur and some of her colleagues, but leaves physicians outside the United State largely unaffected.