February 1, 2008

Female Infant Circumcision? Oh, You Mean The Indonesian Bris?

I've been too unsettled about the New York Times' recent article on female infant genital cutting ceremonies in Indonesia to write about it.

Though there's the obligatory quotes from human rights and womens' health advocates, for the most part, the article treats the ceremonial removal of significant parts of an infant's genitalia in a touching, heartfelt way--as if it were, say, a bris.

Of course, at a bris, there's no female authority figure claiming it'll benefit the boy because, "One, it will stabilize his libido, Two, it will make a man look more beautiful in the eyes of his wife. And three, it will balance his psychology.”

Something to think about.

A Cutting Tradition [nyt]


There have been claims throughout history, by authority figures both male and female, that male circumcision would reduce masturbation. It certainly reduces the number of nerve endings on the penis. The "male circumcisions improves aesthetics" argument is still very common. I don't know about balancing psychology, but there are various arguments that male circumcision benefits health, including one by a female authority figure cited in the NYT article. Those claims, including the most recent claim that circumcision somehow reduces HIV risk, have generally been disproved or widely disputed.

Bottom line is that I fail to see the difference between male and female circumcision, except that we have a cultural preference in the U.S. for male circumcision and a cultural aversion to female circumcision. Personally, I find them equally unsettling.

[do you have a link disproving/disputing the recent HIV/circ studies? I thought those were substantive, but only related to adults. -ed.]

The circ/HIV thing is very controversial. The link I've posted makes the case against.

This whole thing is about promoting circumcision, not about fighting HIV. Abstinence, Being faithful, and Condoms (ABC) protect against HIV, so why is anyone trying to promote genital surgery? Circumcised men are less likely to use condoms, so this whole thing will cost lives, not save them.

In Rwanda, (where they just rolled out a nationwide circ programme), 3.8% of circumcised men have HIV, compared to 2.1% of intact men, so what the heck do they think they're doing? That's nearly twice as many. I'm not (of course) saying circumcision promotes HIV transmission (though it might) but clearly something else is going on. These figures are from the 2005 Demographic and Health Survey ( http://www.measuredhs.com/pubs/pdf/FR183/15Chapter15.pdf , p10 and p15).

There is strong evidence that female circ protects against AIDS btw (http://www.ias-2005.org/planner/Abstracts.aspx?AID=3138).

[first, I can't believe you make such a strong assumption that the hiv studies are about "promoting circumcision." Do you have any citation for that, because otherwise it sounds like ridiculous intactivist spin and does no service to the non-circ argument. Neither does random datapicking in the face of several multi-country controlled studies. My questioning about the studies is about their applicability: does findings of adult circ in HIV-ridden Africa have any bearing on a parents' decision for a newborn baby in the developed world? I don't think anyone involved with the studies is making that leap.

as for the "strong" evidence that female circ *protects" against HIV, the first-round study you link to sounds like an incredible, inconclusive mess. I guess I'm still waiting. -ed.]

I think it would be pretty tough to find any reputable study disproving the link circumcision/HIV given that multiple observational studies, three randomized clinical trials, and systematic reviews all show male circumcision does in fact reduce the risk of HIV transmission by at least 50% and often much more. A summary of much of this research is available at the CDC, with links to the multiple articles on the topic (all published in high quality peer reviewed medical journals).

In addition male circumcision reduces the risk of other STDs and the spread of cervical cancer. Medical complications of male circumcision (especially for infants) are far lower than for female "circumcision" (the removal of tissue for women is so much greater that using the same name is hugely suspect), plus there are no known positive health effects for women and many negative complications like the increased risk of dying in childbirth.

Moreover, as you note, no one has ever claimed that men should be circumcised because it will keep them from sleeping around. Male circumcision was historically practiced for hygienic reasons in desert cultures (which is why Jews and Muslims are religiously and culturally attached to the practice).

If you can't make an argument against male circumcision without making wild leaps of logic to female genital mutilation, you don't have much of an argument. I think there are reasonable positions on both sides of the male circumcision question (especially for infants), but when I hear people claiming there's no link to HIV or that removing the foreskin from the penis is somehow comparable to removing all of female sexual organs and then sewing up the vagina, they lose all credibility.

[the NYT article reports that there are varying degrees of female cutting, and it mentions the full removal and sewing up as being considered a "rural" tradition. What caught me off guard about the article was the almost casual, tender reasonableness with which it described the female cutting, the same way most people consider male circ in the US or Jewish culture. Whereas normally, female circ. is treated as a barbaric, anti-feminist, human rights abuse. I mean, it's banned in many countries and states. Could you ever conceive of someone banning male circ in the US as a barbaric assault? Whatever anti-circ activists think, it ain't gonna happen. -ed.]

The editorial note in the first comment makes the key point on HIV and circumcision. Voluntary, adult circumcision. Those first two words are key, but most people ignore them and focus exclusively on the third.

I'm not interested in denying the results because doing so is unnecessary. The ethical flaw of forced circumcision on healthy individuals overcomes any potential results that might be achieved. For me, the main problem with the studies is that the results, in context, are what they are, yet scientists are still theorizing how circumcision can achieve them. The mechanism, the perceived benefit from voluntary, adult circumcision is unknown scientifically. That shouldn't be ignored.

As to the other claims Dorothy lists, the ethical flaw of forced circumcision on healthy individuals makes them moot for infants. All infants face risk by virtue of being born. it's not our job to remove it all because there are costs to doing so. For example, it's only a partial picture to claim that circumcision was historically practiced for hygienic reasons. The origin of mass, non-therapeutic genital alteration (of both genders) in the U.S. and England as a method to "increase sexual morality" is relevant. Why did they believe what they believed?

There is also an exact moral/ethical equivalence with practices on males and females: medically unnecessary genital cutting on a non-consenting individual is wrong. Gender doesn't matter. Parental preferences don't matter. Religious rites don't matter. Potential benefits don't matter. No one has the right to impose unnecessary surgical alteration on another. It's a clear human rights violation.

It's easy to overlook that when an incomplete picture of the issue is used. Yes, the worst forms of FGM are worse, physically. But that is not the only type of FGM. The WHO recognizes 4 types, with at least one form undeniably causing less damage to a female's genitals than circumcision causes to a male's genitals. Yet we correctly view "lesser" types of FGM as wrong, going so far as to exclude even the most minor symbolic pinprick of the genitals for females in our laws. Only medically necessary surgery may be considered. Her rights are all that matter, as it should be.

No one here would support loosening our FGM laws to permit cutting equal to or lesser than the cutting of male circumcision. It's incorrect to ignore the gender bias against males that violates our equal rights protections. When the child is healthy, it is improper for anyone to impose surgery on another person, regardless of that person's age, gender, or relationship to the decision-maker. Basic human rights are inherent to all, regardless of tradition and good intentions.

"When the child is healthy, it is improper for anyone to impose surgery on another person, regardless of that person's age, gender, or relationship to the decision-maker"

That's where I fall too. No matter what minor costs and benefits circumcision brings, I can't see having a foreskin as so potentially dangerous that a preemptive surgery on a person unable to consent for himself is ethically justified.

I think that infant male circumcision is an interesting question, and far less clear-cut than either side believes because we make comparable choices for infants all the time and always have. I work in a medical center and so get a great picture of cognitive dissonance, e.g. people who don't want to vaccinate their infants because needles are "too invasive" but have pierced their six-month-old daughters' ears. All kinds of cultures have pushed incredibly invasive physical modifications for aesthetic reasons on children for years; aboriginal cultures that cut a lengthwise slit in adolescent boys' penises around puberty are just one example.

Personally I wouldn't want to change my minor children's bodies for solely aesthetic reasons (meaning FGM is out and so are pierced ears), but as soon as there is evidence of a health benefit, we're in a gray area where people draw lines in different places. Some parents won't vaccinate their kids or let them have blood transfusions, etc. Some parents don't care about exposure to lead paint. Personally, I would have the dentist put a crown on my kid's tooth (and this is a form of surgery, as is the very common wisdom tooth removal) whether or not she consented and even if the dentist said she would be okay without one but have a higher risk of losing the tooth later. And potentially losing a tooth is a pretty minor health impact, although it's real. Personally I think male circumcision raises similar issues (though without the visceral reaction people get whenever sex organs are involved).

But it's pretty obvious that not many people outside the world of academic medicine are viewing things this way. People usually circumcise their infant sons because it's religiously or culturally comfortable (ignoring the fact that that's a pretty invasive thing to do to a person without at least considering the costs and benefits) or don't because it feels wrong to operate on a baby who can't consent (ignoring the fact that as parents they will do equally invasive things to their kids with far less potential benefit many times in future years without a second thought).

If there were a form of FGM that offered comparable benefits with similar costs, like maybe removing part of the outer labia in exchange for dramatically reducing the risk of something like breast cancer, it would certainly be worth considering from a medical standpoint, especially for families that have high genetic risk. (A more invasive version of this is the women with the breast cancer gene who are deciding to get radical mastectomies.) But it would be culturally impossible. There's a whole department full of medical anthropologists here who could talk your ear off about why this is the case.

I think the last paragraph of the article was very insightful. Often as parents we blindly follow the norms of our cultures without evaluating their benefits. I think we could all do well to examine our parenting habits as an outsider to determine if our behaviors have the results we truly want.

I will never understand why potential medical benefits should be considered. The child is healthy. Every surgery has inherent risks. The actual risks of everything circumcision aims to prevent are low. In almost all cases where something does go wrong in his lifetime, treatments far short of surgery are available and effective. We don't make the connection that rejecting this is bizarre because it's how we already treat females.

We rarely hear the context for any particular risk reduction because that would demonstrate how silly it is to cut children to prevent such risk. More women get breast cancer than men get penile cancer, yet we don't invade the breast tissue of infant girls. More men get breast cancer than penile cancer, if we want to aim for a true assessment of our cultural lapse in logic. Circumcising to reduce a 1/100,000 risk of penile cancer would be laughable if it weren't insane. And given that other industrialized countries manage to achieve similar (or better) risk rates in virtually everything circumcision is supposed to benefit shows that something other than normal anatomy is at work.

It's unethical to try to mitigate risk when the body is healthy, the potential gains are small, and the value of those gains is subjective. We can't know that boy X will not get HIV because he is circumcised. We can't know that he won't get a UTI. We can't know the he would've gotten penile cancer. (He still could, of course.) And if he does, it would be much later in life. Circumcising infants to reduce that deprives him of the decades of normal body he should have.

The ultimate problem with considering these benefits is that they're subjective and each person's preference for trade-offs will be different. Personally, I do not need whatever protection against HIV I have from being circumcised because I don't engage in unsafe sex. I'm not worried about penile cancer because I'm not promiscuous and I don't smoke. For any benefit named, I do not value it more than I value my body and my liberty to decide. For any male who feels as I do, society's assessment of the cost-benefit trade-off is irrelevant, at best, and insultingly dismissive of his basic rights at worst. Without medical need, there is no ethical justification. That's all the matters in the issue. We know parents are irrational (ear piercing but no vaccination). The proper response is to limit their choices to what is objectively legitimate.

Ed: "I don't think anyone involved with the studies is making that leap" (from circ in Africa to circ of newborns in the developed world).

Sadly, they are doing exactly that:
[ http://tinyurl.com/3xva9f ]

The study you describe as "an incredible, inconclusive mess" is because they were trying to explain away the link between female circumcision and lower HIV rates as being due to other factors. They were unable to do this. Imagine that female circumcision was considered acceptable in the USA though - there would have been well-funded studies to explore the link, involving paying female volunteers to be circumcised.

Female circumcision did used to take place in the USA btw, and there are women walking round today with parts of their genitalia missing. One of them wrote a book about it:
Robinett, Patricia (2006). "The rape of innocence: One woman's story of female genital mutilation in the USA."
N.p.: Aesculapius Press. ISBN 1-878411-04-7.

Looking at the HIV rates of intact and circumcised men for an entire country is hardly "random datapicking", when that country has just embarked on a nationwide circumcision campaign, and circumcised men are almost twice as likely to be HIV+.

I'm absolutely serious that I believe that the circ in Africa thing is about "promoting circumcision", and I know that's a very serious charge. The thing is that circumcision can do nothing to help a man who doesn't have unsafe sex with an HIV+ partner. We can educate people to stop doing that, and even if they do it anyway, using condoms will be far far more effective than genital surgery.

There is evidence that :
1) circumcised virgin men are more likely to be HIV+ than intact virgin men
2) women are more likely to be HIV+ if their husbands are circumcised
3) that following circumcision, HIV+ men are more likely to infect their wives than HIV+ men who are intact. (similar to point 2)

It is also plausible, and I believe highly likely, that circumcised men will be less likely to use condoms - partly because they have less sensitivity, and partly because some of them seem to believe that circumcision confers immunity. I've heard a few stories which suggest this. (any partial solution, not just circ, could result in more unsafe sex)

And yet the WHO has gone ahead with alarming haste in recommending large-scale circumcision programmes, rather than continuing with ABC.

The recent research appears to have been designed with a specific outcome in mind. The Auvert study even describes circumcision as being "comparable to a vaccine of high efficacy", which I regard as being ludicrous. The three studies were all linked and none of them was completed (they were all stopped early on "ethical grounds", even though the later results were not as “good” as the later results). The Auvert study was refused publication by the Lancet, and the researchers are still not answering questions from other researchers about their data.

It appears that they like the results they've got, and they don't want them to be questioned. I think they are more interested in promoting male circumcision than they are in fighting circumcision, and I believe that the current drive to promote circumcision will cost African lives rather than save them.

Are the studies about promoting circumcision? One of the authors (Bailey) co-authored (with notable circumcision advocate Daniel Halperin) a strong opinion piece promoting circumcision 10 years ago, long before the studies began. All three studies are light on the kind of self-criticism that is customary in good scientific papers. For example, subjects who seroconverted despite reporting no sexual activity or only protected activity are ignored. The studies were curtailed when they seemed to show a protective effect. In other contexts, this is called "stopping while you're ahead". The evidence the studies produced was modest - in each case only about 40 control (intact) subjects seroconverted, compared to about 20 experimental (circumcised) subjects, yet these are being multiplied by hundreds of thousands to make claims of millions being protected. Many more than those numbers dropped out of the studies: what if seroconverting after a painful and marking operation that was supposed to prevent HIV makes you disillusioned and more likely to drop out? Post-publication criticism goes unanswered.

High ranking figures such as Peter Piot certainly are using the studies to promote circumcision of newborns globally. Much of the HIV-circumcision work falls under US influence, which includes a powerful cultural bias towards (male) circumcision.

"[do you have a link disproving/disputing the recent HIV/circ studies?]" Try www.circumstitions.com/HIV.html , and circumcisionandhiv.com is good.

Part of my last post is missing since I enclosed it in double angle brackets. Here it is again:

Ed: "I don't think anyone involved with the studies is making that leap" (from circ in Africa to circ of newborns in the developed world).

Sadly, they are doing exactly that:
[ http://tinyurl.com/3xva9f ]

"Absolutely, *parents* should consider it," advised Dr. Kevin De Cock, the WHO's HIV/AIDS Department director. The department's Dr. Kim Dickson said: "Men of high risk, be you in Africa, be you in Canada, (male circumcision) will give you an individual benefit."

Here are a few links to articles about studies disputing the claim that circumsicion stops HIV:

http://www.msnbc.msn.com/id/22096758/ (Black and Latino men were just as likely to become infected with the AIDS virus whether they were circumcised or not.)

http://www.sciencedaily.com/releases/2007/06/070620085239.htm (AIDs rates more closely tied to prostitution rates than circumcision rates.)

http://www.nytimes.com/2008/02/04/us/04immune.html?_r=1&ref=health&oref=slogin (Male circumcision does not reduce HIV transmission rates to female partners.)

Much of what I believe has already been said, and very well, by earlier posters. I do want to add that, sadly, most people I encounter are mutilating their boys for aesthetics, not for the so-called health benefits. I get blank stares from said people if I mention STD's and any of these studies. The only thing that seems to get through is being ridiculous, so I ask if they would think it was okay if I shaved off bits of a baby girl's labia. Or to the mothers who prefer the sight of a circumcised penis, I ask if I should then "dock" my son's ears, as I rather like the way pointy ears look, like an elf, you know? How fast would my children be taken away from me, do you think, if I were to do anything like this, and why then, is it acceptable for me to do such a thing to my son's penis?

An example of the aesthetics argument was a bullshit article in Cookie magazine, in which the author actually quoted "Sex and the City" (one of the characters says a natural penis looks like a sharpei). Are you f'ing kidding me? I'm going to cut off part of my son's genitals on your recommendation, quoting a TV show? What a joke for a supposedly sophisticated magazine.

What also cracks me up is the way people talk about how intact penises look "weird". If you are used to seeing a penis the way it looks naturally, the cut ones start looking like little old men, asking, "Hey, who stole my hat?".

i know there's plenty of debate here already, but if you want to delve further into the circumcision controversy, OpposingViews.com, the website i work for, is hosting a circumcision debate between three vetted experts. check that out here.

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