A Philosophy of Nursing Forum
Saturday, January 16, 2010
 
Bear:

First, let's consider your point, in the first three paragraphs of your comment, about penectomy. It is correct that penectomy involves transecting the urethra, whereas FGM ordinarily will not. It is not similarly correct to say or suggest that penectomy has no history, and that it would result in death absent modern medical intervention. In fact, penectomy has been performed for thousands of years under circumstances remarkably similar to those attending FGM, as a part of the eunuch process, and it still occurs infrequently in India. See the article in Indian J Urol. 2007 Jul–Sep; 23(3): 317–318 for the grizzly details, along with the accompanying picture. It is instructive, I think, to compare THAT picture to some of the available pictures of female genitalia post FGM, and then compare both of THOSE to one of the innumerable pictures available on the WWW of a circumcised penis. I think my analogy is apt indeed, although like all analogies, it does not achieve a perfect correspondence.

Now, on to your final paragraph. The first two sentences are:

FGM and male circumcision are both barbaric practices with little to justify them. A classic case of culturally defined stupidity and irrational justification in both western and non-western cultures and clear violations of the rights of the victims.

These two sentences make the following claims about MNC: 1) male neonatal circumcision is an elective “cultural” phenomenon or practice not COMPELLED by medical necessity; 2) MNC is stupid and/or irrational; 3) purported justifications of the practice of MNC are “irrational”; and 4) and election by a parent to have a male neonate circumcised violates that neonate's “rights”. I think claim number 1 is true. In Ireland, for example, I gather that a parent will only rarely elect circumcision for a newborn son (Irish readers can correct me if I am wrong about this), and this decision is not irrational. I think it is perfectly rational to elect MNC or to decline MNC. However, I do not think this is true of FGM. A decision to have a daughter “circumcised” is never rational.
Circumcision, a reply to Bear's objections
I flatly deny claims 2, 3, and 4. I suspect the purported truth of #2 depends on the purported truth of #3. That is, I think that if #3 is false, and there are good reasons for a parent to elect MNC, then a fortiori MNC is then neither “stupid” or “irrational”.

I don't see anything in your comment which justifies claim #3, other than characterizations of the research on the topic as just 1) “appearing” to show that MNC confers some benefit, and 2) “thinly veiled rationalizations.” I have, to date, reviewed over 400 published, peer reviewed studies relating to MNC, as did Benatar and Benatar. I have studied research methods, at the graduate level, under the tutelage of one of the best scientists in her field, and am quite sure that I can tell the difference between rational, responsible inquiry and “thinly veiled rationalization.” I am confident Drs. Benatar and Benatar can as well. The corpus of scholarly, scientific study of the practice of MNC is voluminous, and is published in journals that are not in the habit of publishing articles which either a) merely “appear” to show something, or are merely 2) “thinly veiled rationalizations”.

As regards claim #3, I agree with Benatar and Benatar: the evidence supports the following conclusions: men who are circumcised as neonates are at slightly less risk than uncircumcised men of contracting syphilis, gonorrhea and HIV AIDS (if in a high risk group), and at slightly greater risk of contracting canker and non-gonococcal urethritis; they are at a reduced risk for the most invasive forms of penile cancer; and at reduced risk for UTI. Actually, I think most MNG opponents concede that the evidence DOES show what I claim it does. This is especially clear in light of a careful review of the responses to the Benatars' original target article. None of the respondents, even those which were clearly hostile to the practice of neonatal circumcision, argued that there was NO warrant for believing that neonatal circumcision provides (minimal) medical benefits. All of them focused, instead, on whether such benefits were sufficient to justify the practice in light of what various respondents took to be clear contra-indications associated with the practice. Here, I think, absence of evidence equals evidence of absence. Credible arguments against the position that there are minimal medical benefits to neonatal circumcision simply do not exist.

I assume, then, that those who oppose MNG are claiming that there are contra-indications associated with neonatal circumcision which unequivocally and significantly outweigh any medical benefits of the practice that we might have warrant for accepting as real. And, further, that these contra-indications are so significant that the practice should not be permitted. Bear's next to last sentence alludes to one such purported contra-indication – pain.

Pain is yet another informal fallacy – the red herring. Pain is NOT an argument against the circumcision of male neonates. It isn't even a valid argument against FGM, for that matter. It IS an argument against either practice when they are not accompanied by truly effective anesthesia and post-operative analgesia. But pain can be effectively controlled for far more serious operations – it can hardly be an insurmountable obstacle in this instance.

So what other “contraindication” could there be? The only one on offer is that the procedure somehow leaves the individual harmed, or diminished, in some way, and this usually takes the form of one or more versions of the “less pleasure” thesis I have already criticized. Until, and unless, I am offered ARGUMENTS against the position I have outlined regarding the “less pleasure” thesis, and the research which supports my position, I remain unmoved.

I suppose that it is possible that someone might think that only surgery which is medically necessary, as opposed to “in some way desirable”, should be permitted. I cannot imagine why. In fact, surgery is performed all the time for reasons other than “medical necessity.” Here is an example: otoplasty, or ear pinning. The procedure is almost never a medical necessity, since kids with large ears can ordinarily hear perfectly. It is, instead, elected for cosmetic reasons, and to help children avoid inevitable adolescent ridicule. The same is true for cleft palate and other maxillofacial surgery. These are procedures which are not, strictly speaking, medically necessary, but do confer benefits upon those who undergo them. The “not necessary” argument is less than compelling.

Finally, we come to the last sentence, the one about neonatal “rights”. I would argue that neonates do not have “rights” - what they have are interests that adults have a duty to protect and further. For the reasons I have already adduced, I fail to see that any male has an “interest” in either having, or not having, a foreskin, any more than they have an “interest” in having an appendix or tonsils. That is, whether their lives go well or badly in not going to depend to any degree on the presence of these tissues. And this marks the dramatic contrast between FGM and MNC, since every woman has an interest in having a clitoris, and their lives will go less well without their clitoris than they otherwise would.
 
 
Why No Mention of Neonatal Circumcision back in June?

The redoubtable “Bear” Cox has asked why I excluded male neonatal circumcision in my June “capabilities approach” post. I did so for a number of reasons, but let me just mention a few.

First, to equate the two procedures trivializes the horror of FGM. Male
neonatal circumcision (hereinafter MNC) is in no way as invasive as FMG.
The homologous equivalent to female genital mutilation would be amputation
of the entire penis. I assure all reading this post that I am just as
opposed to THAT procedure as I am to FGM. I love my "Mr. Happy," who has been my friend through many adventures. However, penile amputation is almost never performed, whereas FGM happens to millions of young women every year. Since it almost never happens in our patriarchal world, there is no reason to mention it.

Second, I am persuaded that ALL of the COMPETENT peer reviewed studies
regarding MNC, individually and collectively, establish that the procedure
produces a modest medical benefit, to be balanced against modest medical
risk, usually in the form an undetected bleeding disorder. If anyone,
anywhere, is aware of a similar study or studies coming to the same
conclusion about FGM, often termed clitorectomy, please let me know.

An excellent summary of the state of the SCIENTIFIC literature regarding MNC may be found in Benatar and Benatar, "Between prophylaxis and child abuse: the ethics of neonatal male circumcision"; The American Journal of Bioethics - Volume3, Number (2), Spring 2003, pp.35-48. It is magisterial, and much can be gleaned from reading it, along with the decidedly adversarial responses to it from anti-MNC camp.

This leads to my third reason. I am convinced that those who oppose neonatal
male circumcision (in contrast to those who would simply PREFER not to elect
it for their sons) are either uninformed or intellectually dishonest. Here
is an example in the form of a comment on the Benatar study, noted above, by
an individual named "Rio Cruz":

"Benatar and Benatar (2003) conclude that amputating ... protective, and
sexually important tissue from a nonconsenting infant does not constitute
abuse but is rather a matter for parental discretion."

I have never, in 60 years of life, seen a more egregious example of begging
the question. And this is not an isolated instance; every single article I
can find which criticizes the practice contains an example of either the
"strawman" fallacy or the "begging the question" fallacy (usually both),
coupled with a willful refusal to examine the peer reviewed evidence on the
topic with anything remotely resembling an open mind.

Now, to another reason - my main one, actually. Look carefully at what this
"Rio Cruz" person says. He calls the foreskin "sexually important".
Channeling my inner G.E. Moore, I want to know what, exactly, that is
supposed to mean. The anti-MNCers never clearly say, which, following Moore
again, leads me to conclude that they mean nothing whatsoever. But, let's
apply the principle of charity to that statement, and try to say something
meaningful on their behalf. Perhaps what they have in mind is a claim that
the procedure of MNC produces "negative" sexual sequela in later life. I
call this the "Less Pleasure" thesis. Let's take a look at it.

The literature surrounding the possible sexual sequela of neonatal
circumcision focuses on the tactile stimulation that males receive during
sexual activity. Of chief concern is the role that the male foreskin might
(or might not) play in the "sexual pleasure" a sexually active male
experiences, and so the debate seems couched in terms of the "stimulation"
that foreskin tissue might provide, and what loss of "sensitivity"
maturation without a foreskin might cause. This is why one finds so much
discussion (and disagreement) about, for example, how "keratinized" the
glans is, how "sensitive to touch and pressure" the glans is, and how much
"highly erogenous tissue" is removed by circumcision (By "highly erogenous
tissue," I take those using the expression to mean "tissue within an
erogenous zone of the body," and by "erogenous zone" to mean a part of the
body that is associated with sexual pleasure). It is at this point, I
think, that the discussion "jumps the track," and leads to conceptual
confusion.

The discussion "jumps the track" because the analysis seems focused on
"sensation," in the sense of peripheral nerve receptor stimulation, as the
primary focus of investigation and analysis, whereas I maintain that our
best science, and scientifically informed philosophy, suggests that this is
the wrong way (albeit the "folk psychological" way) to think about sexual,
or indeed any other kind, of pleasure.

There is a surprising dearth of recent philosophical analysis on the general
topic of pleasure. Rather, pain seems to be the usual topic of interest.
The great bulk of the modern philosophical literature on the subject of
pleasure generally centers on the work of Gilbert Ryle, produced in the late
1940's and the early 1950's, and the responses of other philosophers to
Ryle's work. This work was done when psychological research was, for the
most part, either strictly behavioristic or, alternatively, introspective.
Psychology at the time had little in the way of research findings to offer
philosophers which could shed light on the subject, so it is perhaps not
surprising that philosophical reflection and analysis on pleasure soon
faded. However, Psychology has advanced considerably in the succeeding
decades, and philosopher Mayat Aydede has revisited the subject fairly
recently and produced a splendid paper, "An Analysis of Pleasure Vis a Vis
Pain," to be found in Philosophy and Phenomenological Research, 61 (3):
537-70, 2000 (hereinafter "Pleasure Analysis.")

The language of the current discussion on the sexual sequela of neonatal
male circumcision leads one, naturally enough, to think about the issue in
terms of some relationship between the number of nerve endings in the penis,
plus or minus the foreskin, and the quantity and intensity of "sexual
pleasure." I maintain that this is the wrong way to conceptualize the issue,
in light of what Dr. Aydede, and the scientific work he cites, can tell us
about how it is that pain and pleasure happen to happen.

Aydede argues that, from a general understanding of the gate control theory
and the phenomenon of reactive dissociation, some clear conclusions can be
reached about pain. We can best understand pain, he argues, in the
following way (as drastically simplified by me.) We "feel" pain, or are "in
pain" when: 1) pain stimuli from peripheral nociceptors (pain specific
receptors, located primarily in the skin and viscera) arrive at the
somatosensory cortex and at various limbic system structures; 2) in the
somatosensory cortex, these nocioceptor generated stimuli (noxious stimuli,
for short) are identified as pain, and measured in terms of intensity and
the spatio-temporal location of the originating nociceptors; and 3)
simultaneously, in the limbic system, affective response to the noxious
stimuli, in the form of an aversive reaction, is generated. That, in a
nutshell, is how pain happens to happen, when all goes as "nature intends."

Contrast this picture, Aydede suggests, with physical pleasure. It some
ways, the process is parallel, in that the "experience" of "feeling physical
pleasure" usually begins when stimuli from receptor sites arrive at the
somatosensory cortex and the limbic system. However, a marked difference is
already at work. The arriving stimuli do not include any "pleasure" stimuli,
for the simple reason that the human body apparently has no "pleasure"
receptors, as such. We have lots of receptors, including proprioceptors,
thermal receptors, pain receptors, receptors for touch, taste, light and
smell; but no "pleasure receptors." Thus, the somatosensory cortex does not
identify anything as "pleasurable." When we "experience" pleasure, the
somatosensory cortex is busy identifing stimuli, but identifying them as,
for example, touch, taste, pressure, smell, sound, or motion; not as
pleasure. So "physical pleasure" simply is, on Aydede's model, the affective
response to those particular stimuli.

To simplify even further, we do not have pleasure experiences; rather, we
have experiences we find pleasurable. Pain is different; we have pain
experiences that we usually find, well, painful, unless someone gives us
morphine. Aydede helps us here by simplifying even further: "Put crudely,
the suggestion is not that we feel...pleasure and then desire it. It is
rather that the very feeling of pleasure metaphysically consists of our
desiring whatever...sensory information we are simultaneously processing or
reacting to." Works for me. How else can we explain what goes on in certain
nightclubs in San Francisco? How else do we explain all of that "birching"
business going on on British television (see several episodes of "Midsomer
Murders" for examples)? My goodness how they carry on over there!

Thus, if either circumcised William or uncircumcised James experiences "less
pleasure" than the other, we are not going to be able to tell by counting
the number of their respective "erotogenic receptor sites," assuming,
without deciding, that there even are such things. Instead, we will have to
determine which of them is most strongly "desiring...whatever sensory
information" they typically process/react to when engaging in sexual
activity. And this sort of study, I am afraid, is not something opponents
of MNC ever cite.

There are some peer reviewed studies which do provide some information about circumcision's sexual sequela in adults. But this evidence, such as it is,
does not reflect negatively, on balance, on male circumcision in general.
There is a study which indicates that men who have been circumcised in
adulthood find sexual activity more satisfying, overall, roughly 70% of the
time, studies which conclude that circumcised men engage in a greater
variety of sexual activities than do uncircumcised men (specifics available
upon request - email me off post, ladies), and studies which conclude that
circumcised men are less prone to erectile dysfunction than uncircumcised
men, especially in later life (more good news!). To me, these studies hardly
provide warrant for characterizing the sexual sequela of neonatal
circumcision as "negative", but I leave the reader to draw her or his own
conclusions in this particular.

Let's end by returning to the capabilities approach. It is entirely clear
to me that women undergoing FGM are deprived of a "capability" needed for a
fully "human" life. Joyce's Molly's "YES" is absolutely never going to
happen for them. In the case of circumcised males, however, YES happens for
them as least as often as it does for their uncircumcised cohorts, and all
of the evidence we have suggests that they yell "Oh My God", or words to
similar effect, at least as loudly, when "knocking boots". So, while MNC in
the USA is indeed a cultural phenomenon, an expression of an aesthetic
preference on the part of middle and upper class protestant women, it
deprives no one of a meaningful capability necessary to enjoy a fully
"human" life. The same cannot be said for FGM.

So I did mention FMG, but didn't mention MNC. Hope this answers Bear's question.

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