Charleston bioethics debate highlights harm of circumcision

American Academy of Pediatrics experts fail to defend circumcision

The Twentieth Pitts Lectureship in Medical Ethics at the Medical University of South Carolina in Charleston, South Carolina, held on 18-19 October 2013, was the scene of an epoch-making confrontation between advocates of genital integrity and supporters of routine infant circumcision. On the pro-circumcision side were Drs Michael Brady and Douglas Diekema, members of the American Academy of Pediatrics (AAP) Task Force on Circumcision. Arguing for genital integrity were J. Steven Svoboda from Attorneys for the Rights of the Child, supported by ARC Legal Advisor Peter Adler, community activist Aubrey Taylor, and her husband, Angel Alonso Terron. In the following personal report, Steven Svoboda takes up the story.

Brady was my opponent in the debate about whether circumcision is legal and ethical. Diekema, despite initial claims of objectivity, joined with Brady as a proponent of circumcision. Brady gave a presentation on Friday, October 18, 2013 that closely tracked his PowerPoint. My response followed. Our PowerPoint was by that point persuasive enough that, as they each personally told me later, two of the five physician presenters who are not AAP Task Force members were completely convinced by our arguments and went from being pretty strongly pro-circumcision prior to the event to coming to oppose the procedure based on our arguments. (This also is a good testament to the open-mindedness and objectivity of these doctors.)

Following my presentation was a scheduled 45-minute debate between Dr. Brady and me. We each got our blows in, but it quickly became clear that Brady was unaware of recent political developments and pertinent medical studies. On Saturday, we were each allowed five minutes to summarize our views. After I spoke for the full five minutes, Dr. Brady was unable to effectively rebut any of my points, speaking for just over a minute in an effective concession of defeat. Brady referred to me in his short talk as “Dr, er excuse me, Mr Svoboda.” On Friday, Dr. Brady had audibly complained about how the organizers had allowed “non-physician presenters” to speak, of which I was the only one.

On Saturday, October 19, after each presenter spoke, an open discussion ensued amongst all eight panelists for about 2.5 hours, the last half of which was focused on male circumcision. Peter, Aubrey, and Angel each made very powerful and effective points that helped move the discussion further in our direction. Aubrey and Angel also videotaped, as I had arranged with the conference organizers, all conference proceedings on Friday, and were supposed to record Saturday as well but some presenters asked that no recording be done on Saturday and this was agreed to without informing me of the change.

Peter, Aubrey, Angel and I were able to drive home over quite a few key points, such as uncertainty about the effectiveness of circumcision in reducing the risk of heterosexually acquired HIV. Even the AAP is calling for further studies regarding the connection (if any) between male circumcision and HIV, and eminent scholar Michel Garenne says you need a condom even if you are circumcised. In that case, what’s the point of circumcision. Aubrey offered a great analysis of how Dr. Brady was treating a healthy body part as if it were a tumor, thus pathologizing normal, functional tissue.

Dr. Brady said in his PowerPoint: If the benefits can’t be clearly shown to outweigh problems, then circumcision should not be done. I argued, does not the fact that 38 eminent physicians (37 of whom are in Europe) say in the AAP’s own journal that we should not do it in itself cast sufficient doubt that the practice should be stopped? As I asked near the end of the event, “If circumcision is so great why doesn’t the AAP recommend it? I would think the AAP would be taking out ads in the New York Times to say that everybody should get circumcised. Why the weird balancing act in which the AAP says that circumcision is not recommended but that Medicaid should cover it?”

Angel asked if people present could explain the functions of the foreskin and no one answered it, including Brady and Diekema. Brady said, “I don't think anybody knows the functions of the foreskin,” then reiterated, in nearly identical words, “Nobody knows the functions of the foreskin.” I noted that there was not a word about the functions of the foreskin in the 2012 AAP report, and asked, shouldn’t we know something about the functions of the healthy body part that is being removed?

One amusing aspect: Diekema criticized me on Friday for allegedly being unfair in emphasizing a sentence where the AAP admits that circumcision complication rates are unknown. So the next day, in my five minutes, I read three sentences from that same passage in full, quoting directly from the AAP report, and pointing out several other interesting points contained therein. Here's what I read: “The true incidence of complications after newborn circumcision is unknown, in part due to differing definitions of ‘complication’ and differing standards for determining the timing of when a complication has occurred (ie, early or late). Adding to the confusion is the commingling of ‘early’ complications, such as bleeding or infection, with ‘late’ complications such as adhesions and meatal stenosis. Also, complication rates after an in-hospital procedure with trained personnel may be far different from those of the developing world and/or by untrained ritual providers.” I then pointed out all the doubt and uncertainty contained therein: Confusion, complication rates differing, differing definitions, differing standards, unknown incidence. After all this, Diekema alleged in his five minutes that I was still quoting selectively.

The audience saw through all of this eventually. An African woman was smiling at Aubrey toward the end and the whole row of audience members were clearly on her side. Angel and Aubrey and Peter each was awesome. Aubrey had this brilliant time in the sun where she was allowed to speak for over five minutes and through the whole issue into a new light in a brilliant way by developing the detailed analysis I mentioned of the pathologization of healthy tissue. Angel talked about his own experience being an intact man and no one could argue with that. The circumcision advocates tried to blame female genital cutting on patriarchy and argued that if male circumcision was bad, men who have all the power under patriarchy, would have stopped it long ago. In reply to this, Angel talked about male denial and about Sparta, an extremely patriarchal society where men faced extreme oppression, proving that society-wide male oppression can and does exist, even under patriarchy.

[In patriarchal societies, it is the young men and boys who are oppressed by the old men, and who must typically endure painful initiation rituals in order to be able to graduate to adult status and enjoy adult privileges, such as access to women. It is not adult men who are subjected to circumcision in patriarchal societies, but infants or boys.]

I was able to cite those “well-known anti-circumcision groups” the United Nations, the Council of Europe, and the other European organizations that I didn’t fit into my PowerPoint on Friday. The circumcision advocates could not say much about that, except to offer the response that I was just citing individuals, not all of Europe. Diekema accused me of oversimplifying, and I responded that no, these issues are incredibly complex and I wasn’t oversimplifying anything. Rather, I used the word “Europe” to describe the location of several countries that have recently found non-therapeutic circumcision of children to be illegal. Then Diekema said that those are only physicians’ groups, and hence not all physicians, and that I was oversimplifying again. This weak argument essentially refuted itself.

After we effectively prevailed in Saturday’s panel, Brady responded by claiming that he had inside information that both “Australia” (presumably the Royal Australasian College of Physicians) and Canada are about to issue position statements echoing that of the AAP. No evidence was presented, however, and one may be forgiven for suspecting that perhaps no such evidence exists. Overall, this debate was personally perhaps the single most gratifying experience I have had in my nearly two decades as a promoter of genital integrity. Papers arising from the conference will be published in a special issue of the Journal of Law, Ethics and Medicine next year.

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