Charleston Debate Marks Turning Point in Movement to Recognize Circumcision as a Human Rights Violation
by Steven Svoboda

The Twentieth Pitts Lectureship in Medical Ethics at the Medical University of South Carolina in Charleston, South Carolina, held on October 18-19, 2013, marked an awesome team win that activists for genital integrity were able to achieve when I debated Michael Brady and effectively also debated Douglas Diekema, two members of the American Academy of Pediatrics (AAP) Task Force. Other team members present and helping with this landmark success were ARC Legal Advisor Peter Adler, longtime activist Aubrey Taylor, and her husband, Angel Alonso Terron.

(l. to r.) Steven Svoboda and Michael Brady debate in Charleston

(l. to r.) Steven Svoboda and Michael Brady debate in Charleston

The take-home message is that my Charleston co-author Bob Van Howe, M.D. was completely correct when he told me that we know the science of circumcision far better than the AAP does. We’re going to win eventually. It’s just a question of saving as many babies as we can over the next few years until this practice dies out, as it definitely will.

Michael Brady, M.D. was my opponent in the debate about whether circumcision is legal and ethical, and also present was a second AAP Task Force member, Douglas Diekema, M.D., who despite initial claims of objectivity, joined with Brady as a proponent of circumcision. Dr. Diekema also tried to intimidate me and question my qualifications to speak, noting at the opening social event that I was the only non-physician participating.

Dr. Brady had a smooth presentation on Friday, October 18, 2013 that closely tracked his PowerPoint, which didn’t really have any new arguments or ideas that we hadn’t heard before. He resuscitated the long-discredited 1989 study on UTIs by Thomas Wiswell, M.D., whose results no later researcher was able to duplicate.

My response followed, and all the writing and refining of the paper and presentation over the last 4.5 months paid dividends. I thought that I did very well in my talk, maybe one of my best ever. Astonishingly, I went through my PowerPoint slides faster than I did when practicing and ended up ad-libbing the last few minutes, which probably went at least as well as, if not better than, when I was reading from my slides, as I was able to discuss human rights in some detail and its applicability to this issue.

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 pretty clueless regarding recent political developments and even 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 successfully rebut any of my points, and kept on referring to me as “Dr., er excuse me, Mr. Svoboda.” On Friday, Dr. Brady audibly complained about how the organizers had allowed “non-physician presenters” to speak, of which I was the only one. This was a bit amusing, really, because we ended up proving that our “lay” knowledge as non-physicians greatly exceeded that of the alleged medical experts. This was personally perhaps the single most gratifying experience I have had in my nearly two decades as a promoter of genital integrity.

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. The organizers also attempted (and as far as they knew, succeeded in their attempt) not to return the video that ARC had arranged and paid for with the agreement of the organizers and with ARC’s agreement to tape the entire two days, not just the parts in which I participated! We only obtained it by covertly copying it before handing over the original thumb drive as requested (without explanation.)

A few of the key points Peter, Aubrey, Angel and I were able to drive home over the two days included:

  • 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, so what does circumcision gain you?
  • Public health cannot trump ethics because Frisch et al. say that the cardinal question is how best to prevent disease.

  • Aubrey had a great analysis of how Dr. Brady was treating a healthy body part as if it is a tumor, pathologizing functional tissue.

  • Dr. Brady said in his Power Point: 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 shouldn’t do it in itself cast sufficient doubt that the practice should be stopped?
  • As I said 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? What are you afraid of? A lawsuit?” I believe that they are afraid of a lawsuit (and not without reason) even though they denied 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 advised them that they need to educate themselves and to read John Taylor’s studies before the next AAP report is issued. We 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? I asked the audience members to query in their own minds: Is it possible that there is any impact whatsoever that colors our view of circumcision, that it’s in our culture and that we’re used to it and that it seems familiar?

One curious aspect: Diekema criticized me on Friday for allegedly being unfair in emphasizing a sentence where the AAP makes admission that the complications 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 (i.e., 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, as I said, we converted two physician members of the panel. My pediatrician wife Paula Brinkley’s commented to me in private that if those two presenting doctors took the trouble to speak to me (especially given that they were sitting on either side of me at Saturday’s panel and I saw one of them at Friday night’s dinner so it was particularly easy for them to do so), probably there were a number of other doctors in the audience who changed their views but didn’t mention it to us.

Peter Adler has been a huge ally though this whole process, working for countless hours with me on the PowerPoint and paper. He also provided great emotional support in Charleston, ran errands for the team, and was generally outrageously helpful.

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 under patriarchy.

I was able to cite the “well-known anti-circumcision group” the UN and the Council of Europe and all of those other European organizations that I didn’t fit into my PowerPoint on Friday. The advocates couldn’t say much about that except they offered the response that I was just citing individuals, not all of Europe. Diekema accused me of oversimplifying, responding that no, these issues are incredibly complex and I wasn’t oversimplifiying anything. Rather, I used the word “Europe” to describe the location of several countries that have recently found circumcision to be illegal. Then Diekema said that those are only physicians’ groups, and hence not all physicians, and that I was oversimplifying again. I rejected that charge as well. By definition, these groups represent all licensed physicians. Therefore, it is accurate to say that Dutch or German doctors, for example, want circumcision banned.

As we 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. I think that we are probably safe in taking this claim equally as seriously as we can take the accuracy of Brady’s suggestion in his talk that all eighteen states that currently are not funding the procedure through Medicaid defunded in response to the AAP’s 1999 position statement. In fact, as we noted in our Power Point, six of the eighteen states defunded prior to 1999, beginning with California’s defunding way back in 1982.

On November 13, we submitted our paper to the Journal of Law, Medicine, and Ethics, which is publishing a special issue in early 2014 devoted to the proceedings at the Twentieth Pitts Lectureship in Medical Ethics.

Steven Svoboda
Attorneys for the Rights of the Child

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