One of our not-so-favorite pedoethicists, Dr. Doug Diekema, in cahoots with our favorite punching bag, Brian J. Morris Ph.D, emeritus (or retired) professor of the University of Sydney, just published a new paper called “critical evaluation of Adler’s challenge to the CDC’s male circumcision recommendation”. Other co-authors are Beth Rivin, Anna Mastroianni, John Krieger and Jeffrey Klausner.

The paper obviously intends to be a response to Peter Adler’s  “The draft CDC circumcision recommendations: Medical, ethical, legal, and procedural concerns”, Int. Children’s Rights 24 (2016), 239–264. It seems that many publications consider Brian Morris the go-to person to review circumcision papers, which also gives him the chance to write lengthy diatribes as response to any paper that oppose the circumcision of children. That way, in the future, Morris can claim that “experts (himself and anyone willing to lend his or her name as co-author) challenged this paper”, always ignoring any response to his response. Man, he can get really tiring.

This is typical Brian Morris’ modus operandi, but recently Mr. Morris has taken to have one of the coauthors appear as the first listed author. Nevertheless, the corresponding author is Mr. Morris.

Once you read the paper, it is nothing but a rehash of Morris’ usual arguments. But before we go into it any deeper, let’s consider the meaning of having Diekema as a co-author:

• Diekema is one of the 8 members of the AAP Task Force on circumcision that authored the AAP Policy statement on circumcision of 2012.
• The Policy Statement and accompanying Technical Report did not make reference to any publication by Mr. Morris
• The members of the AAP Task Force characterized the policy statement as neutral. Diekema himself said to the New York Times “We’re not pushing everybody to circumcise their babies, this is not really pro-circumcision. It falls in the middle. It’s pro-choice, for lack of a better word.”
• Recently (April 2016), a fellow member of the AAP Task Force, apparently a more rational Dr. Andrew Freedman (in spite of circumcising his own baby on his parents’ kitchen table for religious reasons), wrote: “we have to accept that there likely will never be a knockout punch that will end the debate. It is inconceivable that there will ever be a study whose results are so overwhelming as to mandate or abolish circumcision for everyone”

But, when we read this new “critical evaluation”, we find a position that is far more extreme than what the AAP has ever presented. It’s difficult to understand how Diekema decided to lend his name to this paper. Let’s see how some of the typical Brian Morris’ arguments develop in this paper:

• Adler’s criticisms depend on speculative claims and obfuscation of the scientific data

  [Morris seems to think that anyone who opposes circumcision is obfuscating data, and that the decision to circumcise depends only on data, and not on the rights, desires and interest of the patient]

• Adler’s central argument that circumcision in infancy should be delayed to allow a boy to make up his own mind as an adult fails to appreciate that circumcision later in life is a more complex  operation, entails higher risk, is more likely to involve general anaesthesia and presents financial, psychological and organisational barriers

  [To this argument we counter that since 2007 there are some circumcision devices invented with the purpose of making adult circumcision more simple, less expensive and painful, such as the FDA approved PrePex, so it’s up to the medical community to pick up on the new technology and offer those devices – which will likely reduce the cost of adult circumcision to the same levels of neonatal circumcision. It’s likely that the medical community is reluctant to do so because of the reduced profit though. But it’s unscientific to deny that such technology exists and is available at a fraction of the current costs. Besides, a circumcision CHOSEN by one person is less likely to induce psychological harms than one FORCED upon a person when they are too young to remove themselves from the situation]

• Benefits of male circumcision include

  [Morris’ typical lethany… ]

• Circumcision does not impair sexual function or pleasure.

  [To claim this, one would have to define sexual function, and would have to find an accurate way of measuring pleasure. Second, science can’t claim it “does not”. At most it can say “it does not appear to”. Third, far too numerous people know that it in facts alters sexual function and causes sexual difficulties which vary with different people. Brian Morris intended to erase this with a meta-analysis a few years back, but the argument is far from over. Morris himself has said that “The foreskin is an absolute requirement for a mutual masturbation practice amongst homosexual men known as "docking", in which the penis is placed under the foreskin of the male partner” – so if the foreskin an “absolute requirement” for this, then sexual function and pleasure are impacted, at least for this population. Docking is also possible between a male and some females, as long as the male has not been circumcised, so it is not something exclusive of the homosexual population, and even if it was, it would still be within their rights to make an autonomous decision.

• Since the benefits vastly outweigh the risks, each intervention is in the best interests of the child.

  [This statement is particularly troublesome considering Diekema’s involvement on this article; the AAP specifically said: the benefits outweigh the risks (not “vastly”), “but the benefits are not great enough to recommend universal newborn circumcision” and “The true incidence of complications after newborn circumcision is unknown”. Fellow task forcer Andrew Freedman described circumcision as having "some modest benefits and some modest risks". So how Diekema could lend his name to the previous statement is really problematic.

• From that point on, Morris states: “Below, we summarise the scientific and legal evidence that contradicts each of Adler’s arguments”

  [At this point however, I will quote Andrew Freedman, referenced above: “there likely will never be a knockout punch that will end the debate. It is inconceivable that there will ever be a study whose results are so overwhelming as to mandate or abolish circumcision for everyone”]

• At the end of 3.4.1. Morris claims: “As noted above, the CDC found that benefits of IMF (infant male circumcision) exceed risks by ‘100:1’”

  [No, the CDC did not find that. The CDC quoted one paper by Brian Morris where he claims this number, so this is just a circular reference to himself. BTW, this number really has no meaning, it's just an emotional argument disguised as a number.]

Brian Morris is selective as always in what he presents as evidence. For example he claims that “Early circumcision also greatly reduces the risk of penile cancer (Daling et al., 2005; Larke et al., 2011) and prostate cancer (Wright et al., 2012).” On prostate cancer, Wright himself explained to Reuters: “I would not go out and advocate for widespread circumcision to prevent prostate cancer. We see an association, but it doesn’t prove causality.”  That, however, doesn’t matter to Mr. Morris.

Most of the discussion though is really irrelevant. Everyone can find a reference to support their opinion, thus leading to the belief that such opinion is “scientific”. And then ignore any other reference which opposes that opinion, as “unscientific”. But the real argument is not one of science or not. It’s one of body ownership.

Trying to contradict this argument, Morris brings up a YouGov survey: “A recent survey found 29 per cent of uncircumcised men wished they had been circumcised, compared with only 10 per cent of circumcised men who wished that they had not been (YouGov, 2015)” It doesn’t matter to Morris that this is a non-scientific, non-peer reviewed, online survey. As long as it fits his views, he will claim it. However, it is important to notice that such comparison is not symmetric, since any uncircumcised man who wishes he had been circumcised could still opt for adult circumcision, particularly demanding the medical community makes available those devices such as the PrePex which would make adult circumcision more simple and less expensive, without the requirement of general anesthesia; however, any percent of men circumcised during childhood who wishes they had not been circumcised, are largely at loss, since the medical community has nothing to offer in the sense of foreskin regeneration, which once again becomes an argument to support delaying any decision until the person can offer informed consent.

It is important to recognize that scientists, even bioethicists (such as the Benatars, Arora and Jacobs, or Diekema himself) are not immune to religious and cultural bias. The Benatars and Jacobs are of Jewish faith and they make the fact that they consider infant circumcision vital to their Jewish identity (which not all Jewish people agree) clear; Jacobs along with Arora, just like Diekema, have gone as far to defend some forms of female genital cutting of minors as parental rights, something that Morris fails to mention.

On the topic of female genital cutting of minors, Diekema defended the ritual nick explaining that “[It] would remove no tissue, would not touch any significant organ but, rather [it] would be a small nick of the clitoral hood which is the equivalent of the male foreskin – nothing that would scar, nothing that would do damage” – again, a fact missed by Morris in his decision to call Diekema to join hands in this paper.

Diekema himself wrote: “The real art of bioethics is convincing other people why something is right or something is wrong and why something shouldn’t be done or should be done. Many people aren’t going to pay attention to you if that argument is crafted purely in religious language. One of the things that I’ve had to do is craft arguments in the language of the world, which I have not found to be particularly difficult. The reality is that medical ethics has its roots largely in theological ethics, so the basic principles that many people who are not religious subscribe to actually have very strong roots in the Bible and in religious belief.” For the open minded reader I ask, are those the arguments of a scientist or a theologian?

Finally, let’s just remember a few of Diekema’s faults (see IntactWiki for references):

• Clearing the “Ashley treatment” – where a severely disabled girl was subjected to removal of her breast buds, hysterectomy, appendectomy and growth attenuation, a treatment later declared illegal without the order of a court. Dr. Daniel F. Gunther, a doctor involved in this case, committed suicide shortly after for unclear reasons
• Defending the AAP’s policy statement on “Ritual genital cutting of female minors” and the ritual nick.
• Defending parents who allowed a teenage son to die without medical treatment because he believed in faith healing.
• Misrepresenting the death of baby Joshua Haskins in a radio interview (during the presentation of the 2012 policy statement). In this interview Diekema claimed that this case “involved a very sick baby that was likely to die anyway and his parents wanted him circumcised before his death” – when in fact the parents had been fighting along with the baby for his life, and they were told that their baby was now strong enough to tolerate the circumcision – but then allowed to bleed for several hours from the circumcision site, leading to the baby’s cardiac arrest and death.
• Diekema and fellow task force Michael Brady were shamefully defeated in a debate, by Attorneys for the Rights of the Child member Steven Svoboda and his staff, a debate in which Brady declared:  “I don’t think anybody knows the functions of the foreskin. Nobody knows the functions of the foreskin.” One of Svoboda’s staff members was able to point to his experience as intact male, and how his foreskin is part of his sexual life on a regular basis.

After the release of the 2012 statement, Intaction offered Diekema the “Mengele award”, one that Diekema didn’t make a speech for.

Intaction member Anthony Losquadro offers Doug Diekema the “Mengele award”
Photo by James Loewen.

So, after all this, I don’t know who made a more questionable mistake here, Brian Morris by enlisting the questionable Doug Diekema as a coauthor, or Doug Diekema, by lending his name to extreme pro-circumcision arguments that are not even compatible with those of the Policy Statement that he and his fellow AAP Task Force members presented. What do you think?

On May 9th, our friend, intactivist Jonathon Conte committed suicide. While I tried, I couldn’t bring myself to post here. I paid my respects privately and silently.

Last week we became aware that the Tampa Bay Times had published an obituary – including a guestbook. Many noticed that the obituary made no mention of Jonathon’s selfless work in pro of the rights of children – or of his surviving partner.

Jonathon Conte’s obituary on the Tampa Bay Times

Many comments were added to the guestbook- including one that I submitted. One intactivist paid a fee to keep the obituary active.

Today we learn that the obituary – and all comments- have suddenly vanished.

The link to the obituary page returns a 404 error (not found), and the link to the guestbook returns a 200 error.

The guestbook was originally set to be online until 7/3/2016 – before an intactivist paid to make it permanent. So why was it deleted? Who is censoring Jonathon’s work past his death?

It is important to clarify that HR 1150 is not a law yet. It has been approved in the House of Representatives, now it moves to the Senate.

Please contact your senator this week and express your concern. Religious freedom does not apply to another person’s body.

You can find the contact information for your state senators here: http://www.senate.gov/general/contact_information/senators_cfm.cfm

As a person who was once a baby, I feel offended by the idea that my body could be used as accessory to my parents’ religious beliefs, particularly if their religious beliefs call for the permanent alteration of my sexual organs.

Notice that if you are in the United States, the sex of the writer of the above paragraph would be paramount to know if the described act is legal or not. A female writer who expresses dismay over the idea of her sexual organs being permanently altered by her parents would be simply criticizing the odious custom of female genital mutilation. A male writer however, would be considered to be “whining” over the most common surgery in the world -never mind that it is one practiced without medical need- and could probably be labeled as antisemite or islamophobe for claiming ownership of his own body.

Notice also that if your family happens to be an ultra orthodox Jewish family in the North East, it is likely that an old man sucked your penis immediately after cutting part of it with his knife. And in spite of laws protecting children from the actions of pedophiles, this man did so under the guise of religious freedom – and currently protected by NYC Mayor Bill De Blasio.

Do you feel dirty now?

Well, given that some organizations such as the Parliamentary Assembly of the Council of Europe have raised concerns over ritual circumcision of male children as a procedure that violates the physical integrity of children, that numerous European medical and political associations oppose circumcision of children, that a 2012 ruling in Cologne, Germany, led to a temporary ban in circumcision of children followed by the urgent approval of an unconstitutional law to protect circumcision, our beloved American politicians have seen in the best interest of the world to create a new bill to protect religious freedom internationally. They have, of course, mixed the language including references to organizations such as ISIS.

So, this new bill, passed Monday, would broaden the definition of “violations of religious freedom” in the International Religious Freedom Act of 1998 to include the persecution of advocates of male circumcision or ritual animal slaughter. Thus, males of the future will have no resource but to surrender their most private organ to be mutilated and carved for the appeasement of their parents’ religious beliefs, enshrining the routine ritual abuse of male babies.

It remains to be seen if the aforementioned bill will extend the same courtesy to those religious groups which practice the genital alteration of female minors -even when it is not written on their main religious book, or how the bill will deal with the distinctions between religious and cultural practices, and which practices are not protected by it.

For the time being, we can thank Chris Smith, R-N.J. and a hundred or so co-sponsors (including also Marco Rubio, no surprise there), for turning the United States into the religious police of the world, and all the male minors of the world into accessories devoid of personhood, to be sexually used during the parents’ religious practice.

Additionally, in his address in 4/20/2016, Rep. Chris Smith commented on The Strategy to Oppose Organ Trafficking Act (H.R. 3694), saying “we have evidence that organs continue to be harvested without consent from some Falun Gong detainees and other prisoners in China“. Well, Rep. Smith, please let me tell you that infant circumcision allows American doctors to continue to harvest genital tissue without consent from American baby boys, for the profit of the biomedical industry. Will you do something to protect those baby boys?

Read more:

JTA - House passes bill protecting circumcision, ritual slaughter as religious freedoms

World – House passes religious freedom reform bill

South Florida based doctor Christopher Hollowell posted a video of a circumcision of a 1 year old child. During the narration, Hollowell first appears satisfied about the lower rates of circumcision (and even misrepresents it) but as the video progresses, he becomes strongly biased for circumcision.

Dr. Christopher Hollowell

He claims that as a urologist, he sees all the cases where uncircumcised boys have problems. He claims, for example, that the 1 year old child he is circumcising has phimosis and balanitis.

This is problematic already. Most babies are born with congenital phimosis (also known as physiological phimosis), which is a normal condition: the foreskin is not ready to retract. It takes years, for this phimosis to be overcome, with the average age being 10 and a large variance. Being non-retractable at 15-17 is still normal.

Balanitis is often claimed as a reason for non-neonatal circumcisions. However, balanitis simply means inflammation of the penis. Quite often, it’s just an ammoniacal dermatitis resulting from bacteria in the feces staying in the diaper for too long, and can be resolved with medicine and patience, without need for surgery.

The doctor claims the child has severe penile adhesions. What he is doing is patologizing a normal condition. As we have often explained in this blog, the foreskin and the glans start as a single structure, and at some point a layer starts desquamating, creating the subpreputial space. This layer is called the balanopreputial sinechiae or balanopreputial lamina, and it dissolves slowly through several years. But our doctors tend to call it adhesions. The AAP erroneously claims that these adhesions should be resolved by the 4th month of life.

At 1 year of age, these “adhesions” are in fact normal. The foreskin and the glans are still in the process of separating, and there is no need to rush them.

Dr. Hollowell then pulls the foreskin back and claims that the penis of this child has a “cobra head effect” because pulling it down causes the glans to curve downwards, pulled by the frenulum. Based on this observation, he proceeds to excise the frenulum.

Dr Christopher Hollowell cutting the frenulum of a 1 year old boy

Personally, I consider the removal of the frenulum of a child a criminal act. And it is also unnecessary.

It is unnecessary because at 1 year of age, the penis of this boy has not reached its adult size, so any present consideration will completely change during puberty, once production of testosterone increases and the body starts reaching its adult size. So even if the frenulum is short now, it still has plenty of time to grow. Not only that, but even if at 18 the  frenulum was still short (frenulum breve), there are non-invasive ways of correcting it. There is no need to fully remove it.

I believe that removing it is a criminal act because the frenulum carries an artery and a high concentration of nerves. The frenulum itself is said to be one of the most pleasurable parts of the penis -by those who were lucky enough to retain their full frenulum, or did not suffer total damage of it. So, to remove it before the person has attained an age of maturity seems to me a purposely damaging action which has long term effects over the sexual experience of that child.

The loss of irrigation due to cutting the frenular artery can potentially have long term effects. Some suggest that ischemia (lack of blood) is behind the common occurrence of meatal stenosis in circumcised boys. Loss of blood flow could also affect the surface of the glans, as hypothesized by Ken McGrath. Finally, loss of blood flow could be related to erectile dysfunction later in life.

Dr. Hollowell repeats several times that the foreskin is very vascular tissue, yet he doesn’t seem affected by the idea of removing it.

He says that he likes to think of circumcision as plastic surgery of the penis and that he likes to think that every man likes to have a beautiful looking penis. But, isn’t it problematic to perform plastic surgery on the genitals of a child, to think of the genitals of a child in terms of “beautiful looking” as a result of plastic surgery – particularly when performed without consent of the person?

During the procedure he marks the line where he is going to cut. It can be observed that the line is traced around the center of the penis. Now, if we consider that the foreskin is a double layered area, then the total area of tissue being removed accounts for approximately two thirds of the covering of the penis. If it was single layered, it would be one half, but since the foreskin is double layered, it counts two times, thus the total tissue removed is 2/3rds or 66% of the covering of the penis.

Circumcision removing between 1/2 to 2/3 or the penile covering

Hollowell says that when asked why do the procedure at one year and not at birth, his response is that he couldn’t do it before and had to try conservative measures because of the age. He then goes on an explanation about aging and bleeding that has more to do with Jewish myths than with actual science. “The foreskin we’ve learned over centuries that if you cut the foreskin before the 10th day of life you will have very little bleeding of the foreskin, so many cultures will just do it as a ceremony without any problems, however after that time, if you decide to cut the foreskin it will bleed significantly and in young boys, a little bit of bleeding can be devastating“. He says this without acknowledging that the only cultures that circumcise babies are the Jewish and the American culture, not “many cultures“, and the reasons he gives have more to do with bible myths than with any solid science. In fact, babies circumcised on the 8th day according to the Jewish tradition, may still die from exsanguination, as we have previously showed in this blog.

As he explains this, Hollowell keeps cauterizing the penis to stop any bleeding. Has anyone studied the harm caused by cauterizing all those blood vessels? If American doctors were using more recent circumcision technology, they would be able to circumcise children and adults without cauterizing the inside of the penis as if it was a piece of grilled steak.

Dr. Hollowell zealously cauterizing the internal parts of the penis

Now, the real reason why Hollowell performs these circumcisions at 1 year of age has everything to do with insurance and little to do with medical reasons. See, for a few years, Medicaid didn’t cover neonatal circumcisions in Florida. So instead of paying the $200 to $800 out of pocket, many families waited one year at least, and then procured a referral for circumcision. Because there has to be a diagnosis code for insurance to cover it, doctors would diagnose phimosis, knowing very well that they are providing a fraudulent diagnosis because those children are perfectly normal. But at that point, because of the age, the procedure (at least in the U.S.) requires general anesthesia and becomes a more involved surgical procedure (mostly because the American doctors are not using the most recently invented devices for non-neonatal circumcision, which would greatly reduce the cost and risks of the procedure), so now the procedure is up to 20 times more expensive.

This medical fraud is what led one doctor Saleem Islam to claim that the cost of circumcisions in Florida “skyrocketed” after Medicaid stopped covering neonatal circumcisions. Doctor Islam in his paper candidly recognized that parents came asking for circumcision for their children, but didn’t mention that those circumcisions would be fraudulent because they were not based on real medical necessity – so they shouldn’t even be covered at all.

So this is the reason Hollowell is circumcising a 1 year old child over a diagnostic of phimosis and balanitis: because the parents did not want to pay the low cost of a neonatal circumcision out of pocket and preferred to seek a referral after the age of one, for a more complicated and risky procedure under general anesthesia and at a higher cost to the tax payers.

Closer to the end of the video (while suturing the penis) Hollowell goes into his litany of things that can happen to uncircumcised boys: they can have adhesions, they can have balanitis, they can develop penile cancer later, they can have urinary tract infections,  they have more risks of getting STDs… all the myths we’ve heard over and over.

And then he compares circumcision to a vaccine. “And I tell you if you could have a vaccine that gave the same results we would jump at it every time, so it is quite interesting to see where our new thought process is on what we would do to offer this to young boys again on a routine basis”

The lies they say:

• The child has phimosis
• The child has balanitis
• The adhesions are abnormal
• The frenulum causes the penis to bend downward
• Circumcision protects against STDs, penile cancer, etc.
• Circumcision is a surgical vaccine
• He won’t know the difference

The crimes they make:

• Fraudulent use of insurance
• Cutting one of the most pleasurable areas of the penis – the frenulum
• American doctors don’t use the most recent technology for non-neonatal circumcisions – thus increasing the risks, complications and cost of the procedure.
• Subjecting a 1 year old child to general anesthesia for a non-medical surgery (plastic surgery of the penis – give the child a beautiful penis).

Shame on you Dr. Christopher Hollowell.

While in circwatch we often discuss studies, articles and publications, and point their flaws, contradictions and conflicts of interest, we are first and foremost bound to the principles of bodily autonomy and genital integrity.

Performing irreversible “elective” surgery on non consenting individuals violates the principle of bodily autonomy. It denies the person the right to provide informed consent and make an informed choice.

Removing part of the genitals of children without medical consent violates their genital integrity, part of the children’s right to physical integrity.

Both violations are ethically problematic.

Sure, there is often a discussion of whether there are benefits or harm, whether circumcision affects sexual function or sensitivity or not. But that is basically an academic discussion.

Let’s be clear. If a child was in a life or death situation, where not performing a circumcision would easily cause the child to die or be permanently impaired, it would be irresponsible to not do it. But that is not the case with neonatal circumcision or with child circumcision.

As clearly indicated by the AAP and discussed by the members of the task force, circumcision is often a non-medical decision based on cultural, religious or family factors. And that is problematic.

By performing a circumcision on your newborn child, you are denying this newborn person the right to choose, the right to make informed decisions over his own genitals, and you are depriving him of a normal part of his body. As a parent you may have the best of intentions, but you are missing this side of the issue.

Doctors should not be enabling parents. This is often perceived by parents as a recommendation, resulting in tilting the balance without regards for the future preferences or desires of the minor individual.

Even if there is a lower risk of a minor or rare condition, there is also a harm in circumcising. The procedure is irreversible and leaves permanent marks – a scar and missing parts. There are low incidence high impact risks that should be taken into consideration as well.

We are not “anti-circumcision”. We have no issue with people becoming circumcised – as long as they can provide informed consent. But we have problems with people forcing minors to undergo permanent reductive procedures on their genitalia.

Andrew Freedman, of the AAP 2012 Task Force on Circumcision, wrote: “It is inconceivable that there will ever be a study whose results are so overwhelming as to mandate or abolish circumcision for everyone, overriding all deeply held religious and cultural beliefs.” And while this is true, it should not be taken as a carte blanche to override children’s ownership of their own bodies. It should be taken to apply to your choice over your own body, not your choice over someone else’s body. You don’t own your child’s body.

Your child’s body should not be an accessory to your religious or cultural expression. Your child’s freedom of choice and bodily integrity are at stake. Please, respect the dignity and personhood of your child.