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The ethics of circumcision, Part 2


Andrew Gross

Published: March 12, 2023

Updated: July 3, 2024





I encourage visitors to read The Ethics of Circumcision by Brian D. Earp at the following link:



POTENTIAL GAMECHANGER


Earp writes that a significant problem with weighing benefits and risks is that a child who grows up to oppose circumcision has "had one of [his] most intimate body parts irreversibly altered," causing a "permanent loss." He believes that "the inability of the infant to consent to the permanent alteration of their sexual anatomy is, in any view, of considerable ethical significance." He distinguishes between an uncircumcised male who would retain the option of elective circumcision and a male circumcised at birth, for whom "the option of genital intactness ... does not exist." [1]


I will concede that the permanent nature of the surgery has been the strongest argument against elective infant circumcision. However technology is being developed that would neutralize this particular argument. If men can regrow their foreskin, circumcision may no longer be an inescapable condition,


Foregen is a company based in Italy that is developing regrown foreskin tissue for circumcised men. The company's goal is "complete regeneration of the foreskin, with all its neural and vascular infrastructure," including "the frenulum, ridged band and inner foreskin mucosa." [68] After a series of trials involving sheep, Foregen is planning to begin 12 months of human trials. [69] If Foregen is successful and men are able to restore foreskin at a reasonable cost, then irreversibility will no longer weigh in the ethical equation.




CIRCUMCISION AND GENDER AFFIRMING MEDICAL CARE


IMPORTANT NOTE: Circumcision Choice does not take a position on legal or ethical aspects of gender affirming care, which is outside the scope of our mission. In this section I am noting incongruities between Brian Earp's statements on the ethics of circumcision and his statements on the ethics of gender affirming care for minor children.


Brian Earp says that the child's opinion should be the only one that matters for permanent changes to the genitals. In this respect his opposition to circumcision for minor boys appears to conflict with his position on transgender medical care. Earp is American and seems to agree with the current American trend to allow children with gender dysphoria to receive gender affirming medical care.


In 2016 he promoted a paper that supported hormone therapy for transgender adolescents. The author wrote that - with respect to a 15 year-old patient - it is a physician's responsibility to help the patient "receive gender-affirming medical treatment including hormone therapy, from an experienced clinician." The author concluded that if the patient lacks access to such medical care, it is the doctor's responsibility to "initiate hormone therapy with the patient as long as the benefits of providing hormone therapy outweigh the potential risks." [70][71]


In September 2022 Earp wrote that consent is the moral and legal principle that should apply to all genital surgeries. He wrote that surgeries are rare among minors and that it's possible that older teens and adolescents can give valid consent to "circumcision - or to medically approved hormone therapies for gender dysphoria... Gender-affirming surgeries for trans minors are not recommended, although in rare individual cases they could be deemed medically necessary prior to age 18." He calls for better research on the long-term effects. [72] In December Earp declined to take a position on transgender surgery for minors, but he declared that "surgeries will, as a matter of fact, have been deemed medically necessary by their healthcare team: i.e. as a means of eliminating otherwise unresolvable dysphoria." [73]


Indeed, Earp's assertions are not matters of fact.


  • Consent is not a legal principle. The U.S. Supreme Court has affirmed that "the interest of parents in the care, custody, and control of their children is perhaps the oldest of the fundamental liberty interests recognized by this Court." [74] Nor is it clear that a patient's consent is an ethical principle over a parent's right to guide a child's medical treatment.


  • Gender affirming surgeries for minors are not rare. In response to a question by a U.S. Health Department bureaucrat, the co-founder of a Philadelphia gender clinic affirmed that gender transition surgeries are performed on children as young as 15. "I think we have had more than 10 patients who have had chest surgery under 18 (as young as 15) and 1 bottom surgery (17)." [75] Boston Children's Hospital performs top surgeries on children as young as 15. [76] In California a 13 year-old can legally get puberty blockers and a double-mastectomy. [77] At Texas Children's Hopital - the largest children's hospital in the U.S. - a decision to prescribe puberty blockers to children as young as 11 may be made after just one visit. [78] An "analysis of insurance claims found 56 genital surgeries, including vaginoplasty and other procedures, among patients ages 13 to 17 with a prior gender dysphoria diagnosis from 2019 to 2021. That doesn’t include surgeries not covered by insurance." [79]


  • Minors may change their minds. The rate of transgender regret is a matter of heated debate. Supporters of gender affirming care say that patient regret is rare. Studies in the United Kingdom and Sweden showed transition regret of just 0.47% and 2% respectively. (These studies likely involved mostly adult subjects.) [80][81] A U.S. survey of almost 28,000 transgender adults found that 8% reported some kind of detransition, and for a majority, the detransition was merely temporary. [82] A Cornell University study found that up to 3.8% of gender transition patients experienced regret. [83] However others say that gender dysphoria is a temporary condition for most children who experience it. Studies in Britain, Finland, Sweden, the Netherlands, and Germany indicate that "Most children who believe they are transgender are just going through a 'phase;" the vast majority grow out of it and come to terms with their body and sex. [84-86B] (By contrast just 10% of circumcised American men regret their parents' decision. [25]) Government agencies in Sweden and Norway advised caution in prescribing hormone blockers and gender affirming surgery for minors based on the prevalence of detransition. [87-89] An increasing number of patients are filing lawsuits, saying they should not have been given hormone blockers or surgery. [90-92A]


  • The effects of gender affirming care may be severe and permanent. While long-term effects on minors are unknown, the New York Times reported that "[t]here is emerging evidence of potential harm from using [puberty] blockers." Two studies found that the bone strength of many trans patients "while using blockers ... do not fully rebound and lag behind their peers. That could lead to heightened risk of debilitating fractures ... and more immediate harm for patients who start treatment with already weak bones." [93] The director of Boston Children's Gender Clinic stated that puberty blockers can cause the body to "stop ... producing sperm or eggs." [94] "Puberty blockers and sex hormones do not have (FDA) approval for children’s gender care. The effects on [brain development], fertility and sexual development remain unclear." [95] A healthy 18 year-old Dutch patient died after puberty suppression necessitated an intestinal vaginoplasty, which is considered riskier than a standard vaginoplasty. [96] Doctors admitted in confidential emails that some patients developed cancer as a result of hormone treatments. [97] Consequently in 2024 the NHS banned the use of puberty blockers for gender dysphoria in Great Britain. [97A] Earp rejects circumcision of minor boys as a parental choice because "many people" regard circumcision "as serious harm." [98] Yet he flips when it comes to removing or inverting all of a child's genitals in the absence of a clear medical need.


  • Trans affirming health care teams have a financial motive. A physician at Vanderbilt University's transgender clinic promoted gender affirming care because the hospital could make up to $100,000 per patient. "These surgeries are labor intensive. They require a lot of follow-ups. They require a lot of OR time. And they make money. They make money for the hospital." [99][100] A whistle-blower at Texas Children's Hospital reported a figure of $70,000-80,000 per patient. [78] A pediatrician in Pennsylvania asked a state health official to help her explain to her hospital administration the financial revenue that a gender-affirming program could generate. [101] The transgender surgery industry is projected to reach $5 billion by 2030. [101A]


  • Medical professionals rush through the assessment process and often pressure parents to support transition. Out of 18 clinics across the United States interviewed for a recent Reuters article, seven were "comfortable prescribing puberty blockers or hormones based on the first visit" - one meeting with parents and child that can be as quick as 2 hours. "One psychiatrist recommended puberty blockers after a 1-hour consultation with a [13 year-old]; an endocrinologist recommended the same after talking with the family for 15 minutes." [95] An Indiana pediatrician reported that treatment can begin "at the first visit to [a] gender clinic" - without any psychological support. [102] By contrast researchers in the Netherlands take from 6 to 18 months for assessments "before considering medical treatment." [85] A 2024 University of Texas study found that a patient's risk of suicide increased by 1200% following gender affirming surgery. [102A]


Earp's sustained, vocal, and quixotic campaign against circumcision contrasts sharply with his casual, more permissive stance on gender affirming care. He considers circumcision - a simple procedure that leaves the penis fully functional - a "grave moral problem." He favors "the European pattern," and he considers the United States an outlier on the ethics of circumcision. Yet he gently suggests that perhaps "gender affirming surgeries for trans-minors are not recommended," and he calls for "better research on long-term risks and benefits." [72] He ignores the reality that the U.S. is becoming an outlier, as European countries like the United Kingdom, Finland, and Sweden place severe restrictions on hormone therapy. [80-91][103] A standard in which the removal of foreskin is objectionable while removal or inversion of the entire penis - leading to permanent sterilization and lifelong medical treatments - may be acceptable, based solely on a prepubescent or adolescent child's desire, is neither ethical nor logical.



PUSHBACK #2 - Brian Earp hasn't expressed support for gender affirming care for minors.

Earp's stance on hormone blockers and gender affirming surgery could be characterized as cautious. He has not called for a prohibition of such procedures, despite the fact that they can have permanent effects on minor children, including sterilization. By contrast he is constant and inflexible in his opposition to circumcision, a procedure that has no adverse effect on procreation or (arguably) sexual pleasure. (To repeat, I am not making an ethical judgment on gender affirming care for minors; I'm merely noting Brian Earp's ethical inconsistency.)


PUSHBACK #3 - Unlike circumcision, gender affirming care involves the patient's consent.

The question is whether a minor child can understand and appreciate the significant lifelong consequences and make a mature, informed decision about gender affirming treatments. By contrast neonatal circumcision is unlikely to affect a boy's physical, psychological, or sexual development. Moreover, the rate of circumcision regret among men may be much lower than the rate of regret for gender affirming surgery.


PUSHBACK #4 - This is a tangent. The issue is circumcision.

Earp compared circumcision to female genital mutilation, intersex surgery, removing an eyelid, removing an earlobe, and foot binding. If Earp can use analogies to make his point, then I can use analogies to make my point.


PUSHBACK #5 - You’re using a red herring, the tu quoque fallacy. You’re shifting the focus to an unrelated topic in order to avoid dealing directly with Earp’s arguments against circumcision.

On the contrary, I dealt with Earp’s position against circumcision in the previous sections. Here I’m showing that Earp’s obstinance is inconsistent with his position on another medical issue - one likely to have a far more significant lifetime effect on a minor child’s genitals, sexual activities, and mental health.




CHILDREN'S RIGHTS: CIRCUMCISION AND ABORTION


IMPORTANT NOTE: Circumcision Choice does not take a position on legal or ethical aspects of abortion, which is outside the scope of our mission. In this section I am noting incongruities between Brian Earp's statements on the ethics of circumcision and his statements on the ethics of abortion.


Several European nations, particularly in Scandinavia, have reached a remarkable medical milestone: the virtual elimination of Down syndrome. Norway, Denmark, and Iceland have almost no babies born with Down syndrome.


The reason for this medical achievement is a prenatal screening test for Down syndrome, with a positive test often resulting in termination of the pregnancy. In Britain 80% of women who receive a positive test result for Down syndrome terminate their pregnancies. [104] Norway is also at 80%. [105] In Denmark 98% of positive tests lead to termination. In Iceland the figure is nearly 100%. [106] In Europe most fetuses diagnosed with Down syndrome are never born because they are aborted.


Pregnant women in these societies are encouraged to choose abortion. Øjvind Lidegaard, Chairman Professor in Gynaecology and Obstetrics at the University of Copenhagen, told Vice News, "I think that Danish women are less sentimental about aborting malformed fetuses partly because that view is supported by professional medical staff. Recommending abortions isn't an obligation but we give very realistic prognoses. 80% percent of children with malformations end up in an institution and the majority of their families go through many problems. We give parents realistic expectations about future problems and generally, women carrying fetuses with severe malformations are recommended to terminate the pregnancy."" [105]


In Ireland Peter McParland, director of Fetal Maternal Medicine at the National Maternity Hospital in Dublin, admitted, "In some countries there will be some that will have no Down syndrome baby. The science has got way ahead of the ethical discussion. As a society we have not reflected on what the implications are." [106]


I haven't seen Brian Earp express an opinion on the ethics of using abortion to end Down syndrome.



The day after the U.S. Supreme Court issued its landmark decision in the 2022 Dobbs v Jackson case, Earp expressed his clear support for a woman's right to choose abortion. In a series of nine tweets he argued that, "a moral right against being forced to use one's body to carry a pregnancy to term is part of [bodily integrity and genital, sexual, and reproductive autonomy and] therefore fundamental." [107][108]


Earp's support for abortion marks a dramatic shift from his opposition to circumcision. With respect to circumcision Earp frequently appeals to a European majority that is skeptical of parental choice. Yet he ignores the strict European view on abortion. Most European nations have abortion laws that are far more restrictive than those in the U.S. prior to the Dobbs ruling. In Finland abortion after 12 weeks is available only "for a compelling reason," and a woman must get permission from Valvira, the Finnish health authority. [109] In Denmark abortion is prohibited after 12 weeks except in cases of rape, "severe and incurable [fetal] illness or disability," or "if the woman's life is in danger." [110] In Iceland abortion was legal until the 16th week; a 2019 law extended the legal period to 22 weeks. [111] I researched abortion laws in Finland, Denmark, and Iceland because recent efforts to ban circumcision focused on those three nations.


As I stated in Part 1, Earp distinguishes between circumcision and vaccination in part by appealing to a consensus of medical professionals. "The [medically beneficial] standard may well be appropriate for certain interventions into the body, where ... there is very little disagreement among qualified experts as to what those definitions and measurements [of benefits and harms] imply; for example certain childhood vaccinations."


Yet he rejects the lack of medical consensus as a reason to ban abortion. "Those who [believe that] a rights-bearing moral person comes into being at the moment of conception have every right to live in accordance with their beliefs by refusing to have an abortion... But in a secular, liberal democracy, where there is clear disagreement ... there can be no right for those who adhere to one specific highly contentious notion tied to conception ... to force this conception on others against their own beliefs and conscience, much less by means of state-sanctioned violations of others' fundamental rights to security of the person." [104]


Earp cannot have it both ways. If a lack of consensus is sufficient to deprive a fetus of a "right to security of the person" and thus his life before birth, then a lack of consensus on medical benefits is sufficient to deprive him of his foreskin after birth. With no medical consensus, his parents must have a right to choose circumcision during infancy based on their determination that the procedure is in his best interests. With respect to a medical consensus, vaccinations have a near-unanimous acceptance and female genital mutilation has a near-universal condemnation. Meanwhile circumcision and abortion both lie toward the middle of the consensus spectrum.


Earp compares ethics of abortion and ethics of circumcision: "Supporting abortion rights on grounds that people should have personal autonomy over their own genital, sexual, and reproductive anatomy - as indeed they should - while performing non-consensual genital surgeries on others seems a deeply morally confused position." [112] Earp doesn't explain how passage through the birth canal suddenly grants a neonate a right to absolute autonomy over his genital, sexual, and reproductive anatomy. From the perspective of the fetus: his right to bodily autonomy when his life is at risk is not just critical, but paramount. By comparison a right to bodily autonomy when just his foreskin is at risk seems somewhat trivial.


And yet the countries that are most hostile to infant circumcision are the very countries that use abortion to terminate Down syndrome. Iceland and Denmark cannot claim that their medical ethics are based on a child's best interests when it comes to circumcision if they encourage abortion as a final solution to the problem of Down syndrome. Yet these policies align with Earp's position.

In 2019 doctors in Vancouver, British Columbia advised Vanessa McLeod to terminate her pregnancy because her fetus had no hands or forearms and would have no quality of life. Instead McLeod gave birth to a daughter, Ivy, who is thriving. [113][114]


In February 2023 a municipal official in Framingham, Massachusetts complained about the cost to the city when a prenatal screening fails to identify fetal defects. Michael Hugo lamented that the city will have to spend money to educate children with serious defects because those children weren't aborted. "Our school budget will have to absorb the cost of a child in special education, supplying lots and lots of special services to the children who were born with the defect." [115]


Based on Earp's position, it would be perfectly ethical to encourage a woman to terminate her pregnancy because the fetus has no hands or is diagnosed with Down syndrome - in order to reduce medical or education expenses. By contrast Earp would consider it unethical to encourage a woman to give birth to a son with special needs, and then choose circumcision as a cost reduction measure, [116] or because the boy may be incapable of washing his penis.


From the perspective of a fetus diagnosed with Down syndrome, it's clearly not in his best interest for his mother to live in a culture where parents are encouraged to terminate genetic disorders through abortion. "Many people with Down syndrome lead productive and fulfilling lives well into adulthood... today people with Down syndrome are living at home and able to lead independent lives attending school, work, and contributing to society in a multitude of ways." [117] People with Down syndrome get married and have children. [118-120] I would ask readers who are pro-choice on abortion but anti-circumcision this question: For a male fetus with Down syndrome: would it be better for him if his mother is Icelandic or American? [121] In other words, would it be better for him to be aborted with his foreskin ... or to be born and then separated from his foreskin?



Partisans can offer persuasive arguments both for and against abortion, as well as for and against circumcision. One can make an ethical argument in support of a woman's right to choose abortion, as Earp has done. Or one can make an ethical argument against circumcision, as Earp has done. But one cannot make the two arguments simultaneously. There can be no ethical standard that justifies abortion based on a prenatal Down syndrome diagnosis while simultaneously condemning a woman for choosing to give birth to a baby with Down syndrome and then circumcising him. Earp's ethical standard seems to value human foreskin over human life. Such a standard is indefensible, incoherent, and absurd.



PUSHBACK #6 - This is a tangent. The issue is circumcision.

Earp compared circumcision to female genital mutilation, intersex surgery, removing an eyelid, removing an earlobe, and foot binding. If Earp can use analogies to make his point, then I can use analogies to make my point.


PUSHBACK #7 - Unlike circumcision, abortion involves competing interests, so the ethics are more complicated.

This is a fair point. I submit that ethicists should be far more cautious about approving a medical procedure that - when successful - terminates a human life than about passing judgment on a medical procedure that - when successful - terminates a flap of skin.


PUSHBACK #8 - A right to bodily autonomy doesn't apply until birth.

That touches a critical question in the abortion debate: When does a right to life begin? Abortion proponents proclaim that a fetus doesn't have a right to life until birth, while opponents claim that a right to life begins at conception. Since there is no consensus on the benefits and risks of circumcision, Earp argues that the procedure must be delayed until the child is old enough to consent. In terms of abortion, there is even less of a consensus on when a right to life (or bodily integrity) begins. If Earp were consistent in his reasoning, he would either change his position on abortion or change his position on circumcision. (To repeat, I am not making an ethical judgment on abortion; I'm merely noting Brian Earp's ethical inconsistency.)




CONCLUSION

Since 2012 Brian Earp has written more than 60 papers, articles, book chapters, and blog posts - and delivered more than 50 lectures and speeches - about the effects and ethics of circumcision. [122] At an international conference of intactivists in 2016, he received the "Jonathon Conte Award for furthering the cause of Genital Autonomy.". [123] He presented the keynote speech at the next biannual conference. [124]


In this chapter and throughout his career, Earp has used FGM to frame the issue as one of three patterns: In one culture, circumcision and female genital mutilation (FGM) are prevalent. In another culture, circumcision is prevalent but not FGM. In the third culture neither circumcision nor FGM is prevalent.


A false equivalence fallacy "occurs when someone incorrectly asserts that two or more things are equivalent, simply because they share some characteristics, despite the fact that there are also notable differences between them." [125] Earp has spent his career trying to impose a false equivalence of circumcision and female genital mutilation. Ironically on this matter Earp and other intactivists find themselves on the same side as female genital mutilation proponents. These strange bedfellows try to equate circumcision and FGM - but for opposite reasons. Earp and the intactivists wish to end circumcision; whereas FGM proponents seek to legalize female genital mutilation.


If one follows the title of Earp's chapter The Ethics of Circumcision and focuses solely on the question of circumcision, the third pattern disappears and the regions that practice that pattern are incorporated into the first pattern. I would submit that the second region should also be incorporated into the first region. In other words, there is actually only one pattern: parents are authorized to make the circumcision decision for their infant sons. This pattern is universally recognized in every culture and every country on earth. In this pattern circumcision is legal and parents have a right to choose circumcision for their infant sons. By contrast international consensus recognizes that FGM is a human rights violation, and the vast majority of nations have banned the practice.


In his conclusion Earp states, "I am not arguing that there should be, at this point in the cultural conversation, criminal penalties applied to parents, doctors, or religious circumcisers..." (emphasis added.) This assurance is both disingenuous and telling. It is disingenuous because “at this point” implies that his hesitancy is not based on principle, but is merely strategic. Earp anticipates a future point - once a sufficient portion of a population supports his position - when he would endorse penalties for any remaining holdouts. He made this point more explicit in December, tweeting, "Calling for criminalization in advance of sufficient cultural change has so far led to reactionary laws protecting 'parental right' to cut." (emphasis added) [126]


Indeed, in 2018 Earp wrote to the parliament in Iceland, a country where a proposed circumcision ban had near-majority support (50% for and 37% against). [127] He concluded, "if non-therapeutic female genital cutting is unlawful, then so must be non-therapeutic male genital cutting." He included eight essays that he authored or coauthored - 169 total pages - clearly hoping to influence legislators to approve the ban. [128] Earp even argued that the proposed legislation didn't go far enough because it would allow parents to choose circumcision for "health reasons" that could include preventative, hygienic, or even social benefits. [129] He also endorsed arguments in support of a ban in Denmark. He commended a 2021 letter written by an American to the Danish prime minister as "Powerful words." [130][131] So Earp is being less than honest when he denies his support for criminalization. He supports an immediate ban in countries where circumcision is politically unpopular, and he's actively trying to convert the populations in other countries to consider a ban.


Earp's support for a circumcision ban for all boys under 18 seems to conflict with his acknowledgement that "it is possible that some [older teens and adolescents] can give their own valid consent to ... circumcision." [72] If a patient's desire is the guiding principle, then it is unethical to deny or delay the medical and sexual benefits of circumcision to an informed (and presumably sexually active) 16 year-old who desires the procedure for himself.


Earp's disingenuous assurance is telling because it contradicts his conclusion. He labels circumcision not only "a grave moral problem" and "an extraordinary moral wrong," but "sexual assault" and "an especially serious violation of [a baby's] personhood." One who actually believes that a serious sexual violation is occurring would not settle for merely attempting to persuade the violators to stop committing the act.


Consider abortion opponents, who say that abortion ends a human life. They don't settle for merely holding protests outside abortion clinics seeking to persuade pregnant women to continue their pregnancies. They also seek to enact legislation to limit or prohibit abortions. Consider opponents of gender affirming health care, who call it "mutilation" and argue that puberty blockers and surgery cause permanent harm. They, too, are holding protests. And they are also enacting statewide legislative bans. Whether you agree or disagree with them, opponents of abortion and transgender care are acting in alignment with their stated views.


By contrast Brian Earp gives scholarly speeches, composes academic papers, and writes a few letters. His passivity belies his claims. If circumcision actually were a grave moral problem, an extraordinary moral wrong, actual sexual assault, and a serious violation, Earp's passive criticism would be grossly insufficient. By his reasoning each day that circumcision remains legal, thousands of American children suffer "extraordinary" harm. Future generations of American babies can't wait decades for him to persuade a majority. If Earp actually believed that circumcision were sexual assault, he would be acting with the same urgency displayed by opponents of abortion and transgender care.


In every presentation and paper Earp has invariably sought to compare circumcision and female genital mutilation. (In his latest chapter he also compared circumcision to intersex surgery.) By contrast women's rights advocates and medical authorities routinely explain why female genital mutilation is a human rights violation - without any need to compare FGM to any other transgression. [132] Earp uses FGM and other bona-fide human rights violations as crowbars to pry open the door to a circumcision ban. He seems incapable - or at least unwilling - to judge circumcision simply on its own merits. If circumcision were actually harmful and unethical, Brian Earp wouldn't need to compare it to anything else. Ironically, by using a false equivalency he refutes his own case.



PUSHBACK #9 - You accuse Earp of insincerity because he advocates for circumcision bans in Europe. Yet you also accuse him of insincerity because he hasn't called for a circumcision ban in the U.S. You can't have it both ways.

Those are two separate points. Earp's support for bans in Iceland and Denmark refutes his claim that he doesn't currently support legislation to criminalize circumcision. His procrastination in demanding an immediate ban in the United States refutes his assertion that circumcision constitutes sexual assault and a serious violation of human rights. So yes, I can have it both ways.



RELATED



[1] Brian D. Earp; "The Ethics of Circumcision" - chapter in The Rowman & Littlefield Handbook of Bioethics; November 2022

[25] A 2015 YouGov survey of American men reported that 86% of circumcised men and 67% of uncircumcised men were satisfied with their circumcision status. Just 10% of circumcised men and 29% of uncircumcised men wished that they were the opposite status.

[69] Foregen Staff; "Foregen's Human Clinical Trial"; Foregen; December 22, 2021

[70] Brian D. Earp tweet; December 20, 2016

[71] Cary S. Crall, MD and Rachel K. Jackson; "Should Psychiatrists Prescribe Gender-Affirming Hormone Therapy to Transgender Adolescents?"; AMA Journal of Ethics; November 2016.

[72] Brian D. Earp; "Protecting Children Or Policing Gender?" Practical Ethics; September 20, 2022

[73] Brian D. Earp, Jasmine Abdulcadir & Lih-Mei Liao; "Child genital cutting and surgery across cultures, sex, and gender. Part 1: female, male, intersex—and trans? The difficulty of drawing distinctions"; International Journal of Impotence Research; December 2, 2022

[74] Troxel v. Granville, 530 U.S. 57 (2000)

[75] Nadia Dowshen; email to Rachel Levine MD; May 4, 2017. "I'm not aware of existing literature, but it is certainly happening. I think we have had more than 10 patients who have had chest surgery under 18 (as young as 15) and 1 bottom surgery (17)."

[76] DJ Calligraphy tweet; February 8, 2023. "At Boston Children's Hospital, for top surgeries we'll see people as young as age 15..." - Elizabeth Bodley, PhD, MPH, LICSW, MSW; Social Worker, Center for Gender Surgery

[78] Christopher F. Rufo; "They're Wanting to Play God"; City Journal; May 23, 2023

[79] Robin Respaut and Chad Terhune; "Putting numbers on the rise in children seeking gender care"; Reuters; October 6, 2022

[80] Skye Davies, Stephen McIntyre, Craig Rypma; "Detransition rates in a national UK Gender Identity Clinic", p 118; 3rd Biennial EPATH Conference: Inside Matters, On Law, Ethics and Religion; April 11, 2019

[82] Sandy E. James et al; "The Report of the 2015 U.S. Transgender Survey", p 111; National Center for Transgender Equality; December 2016

[83] Nathaniel Frank, Ph.D. et al; “What Does the Scholarly Research Say about the Effect of Gender Transition on Transgender Well-Being?”; What We Know Project, Cornell University; 2018

[85] "Uppdaterat kunskapsstöd för vård vid könsdysfori hos unga" (Updated knowledge support for care for gender dysphoria in young people); Socialsyrelsen; December 16, 2022. [86] Leor Sapir tweets; January 31, 2023

[87] Annikka Mutanen HS; "Nuoruusiän suku­puoli­ahdistusta hoitava professori sanoo ei ala­ikäisten juridisen suku­puolen korjaukselle"; Helsingin Sanomat; January 27, 2023. “Neljä viidestä vastakkaiseen sukupuoleen identifioituneesta lapsesta kokee murrosiässä taas toisin.” TRANSLATION: "Four out of five children who identify with the opposite sex feel differently in adolescence."

[88] "Care of children and adolescents with gender dysphoria - Summary"; Swedish National Board of Health and Welfare; February 2022

[89] "Pasientsikkerhet for barn og unge med kjønnsinkongruens" (Patient safety for children and young people with gender incongruence); Ukom; March 9, 2023. "Kunnskapsgrunnlaget, spesielt forskningsbasert kunnskap for kjønnsbekreftende behandling (hormonell og kirurgisk), er mangelfullt og langtidseffektene er i liten grad kjent. Dette gjelder særlig for tenåringspopulasjonen der stabiliteten til deres kjønnsinkongruens heller ikke er kjent." TRANSLATION: "The knowledge base, especially research-based knowledge for gender-affirming treatment (hormonal and surgical), is insufficient and the long-term effects are little known. This is particularly true for the teenage population where the stability of their gender incongruence is also not known."

[91] Samuel Lovett; "Tavistock gender clinic facing legal action over 'failure of care' claims"; Independent; August 11, 2022

[92] Christina Buttons; "Second Lawsuit Filed in U.S. Against Medical Transition of Minors"; Reality's Last Stand; June 14, 2023 [92A] Kelsey Bolar; “The Detransitioner Taking on the American Academy of Pediatrics”; Independent Women’s Forum; December 13, 2023

[93] Megan Twohey and Christina Jewett; "They paused puberty, but is there a cost?"; New York Times; November 14, 2022

[95] Chad Terhune, Robin Respaut, and Michelle Conlin; "As more transgender children seek medical care, families confront many unknowns"; Reuters; October 6, 2022

[97] Daniel Martin; "Doctors admit link between transgender hormone therapy and cancer"; Yahoo News; March 4, 2024

[97A] Connie Dimsdale, "Children no longer prescribed puberty blockers in England, NHS confirms"; iNews; March 12, 2024

[98] Brian D. Earp and David M. Shaw; "Cultural Bias in American Medicine: The Case of Infant Male Circumcision"; Journal of Pediatric Ethics; Summer 2017

[99] Dr. Shayne S. Taylor M.D.; "The Clinic for Transgender Health: A Passion Project for our Patients; Vanderbilt University School of Medicine, LGBTQ Health Grand Round lecture series; November 14, 2018. "These surgeries make a lot of money. So female-to-male trans-reconstruction could bring in $40,000. A patient just on routine hormone treatment, who I'm only seeing a few times a year, can bring in several thousand dollars if it requires a lot of visits and labs. It actually makes money for the hospital... They're quoting roughly around $20,000 for a vaginaplasty. But that doesn't include your hospital stay. That doesn't include your post-op visits. That doesn't include your anesthesia, your OR. So I would think that this has to be a gross underestimate... And then the female-to-male bottom surgeries: these are huge money makers. Again, I think this has to be an underestimate. If they're quoting around $20,000 for a phalloplasty, there's been different things that I've read that said it could be up to $100,000. Dr. Winocour, who's our surgeon, says that there's entire clinics where the entire clinic is supported just by their phalloplasties. And that is, like, a fraction of the surgeries that we're doing. These surgeries are labor intensive.. They require a lot of follow-ups. They require a lot of OR time. And they make money. They make money for the hospital."

[100] Matt Walsh; "Matt Walsh Investigates Nashville Gender Clinic" Matt Walsh YouTube channel; September 20, 2022

[101] Rollyn M. Ornstein, MD; emails to Rachel Levine, MD; December 20-21, 2018. Reported by Megan Brock tweets; February 16, 2023. “I am trying to convince the administration about the need for a MSW position specific for the imminent Gender clinic, I am trying to put together a presentation re: potential revenue, including downstream... I am trying to give them some numbers to help them realize the eventual ROI [return on investment] for this necessary position. Even if the patients under 18 who go for surgery might be limited, the patients we start with will eventually be over 18…so I still think it’s worthwhile.

[101A] Ian Miles Cheong; "Transgender surgery industry projected to grow to $5 billion"; Rebel News; October 5, 2022

[102] Jennifer Block; "Gender dysphoria in young people is rising - and do is professional disagreement"; BMJ; February 2023. "Sarah Palmer, a paediatrician in private practice in Indiana ... says, 'I've seen a quick evolution, from kids with a very rare case of gender dysphoria who were treated with a long course of counselling and exploration before hormones were started,' to treatment progressing 'very quickly - even at the first visit to gender clinic - and there’s no psychologist involved anymore.'"

[102A] John J. Straub et al; "Risk of Suicide and Self-Harm Following Gender-Affirming Surgery"; Cureus; April 2, 2024. "Individuals who underwent gender-affirming surgery had a 12.12-fold higher suicide attempt risk than those who did not."

[104] Julian Quinones, Arijeta Lajka; "'What kind of society do you want to live in?': Inside the country where Down syndrome is disappearing"; CBS News; August 15, 2017

[106] Ronan McGreevy; "Citizens’ Assembly hears ante-natal screening poses ethical issues"; The Irish Times; January 7, 2017

[107] Brian D. Earp tweets; June 25, 2022. "Those who adhere to a religious worldview or metaphysic according to which a rights-bearing moral person comes into being at the moment of conception has every right to live in accordance with their beliefs by refusing to have an abortion - in just the same way that a competent Jehovah's Witness has the right to refuse a blood transfusion based on the metaphysical commitments of their religion. But in a secular, liberal democracy, where there is clear disagreement among various religious and metaphysical views about the point at which fetal life assumes rights-bearing moral personhood, there can be no right for those who adhere to one specific, highly contentious notion tied to conception - i.e., as an article of faith - to force this conception on others against their own beliefs & conscience, much less by means of state-sanctioned violations of others' fundamental rights to security of the person."

[108] This statement elicits two reactions. First: Earp doesn't explain why his "security of the person" mandate could not be applied to a fetus. Second: the statement falsely implies that opposition to abortion is based exclusively in religion. Yet the anti-abortion movement includes atheists and other secular opponents. For example, see: Mary Fiorito; "Atheists against abortion reject the religious narrative"; Our Sunday Visitor; July 31, 2022. “'You absolutely do not need to believe in a God to oppose the intentional taking of human life,' insists Herb Geraghty, executive director of Rehumanize. 'Many atheists, like myself, who embrace a consistent ethic of life, oppose abortion for the same reasons we oppose things like the death penalty, war and police brutality. Abortion is a human rights violation, and everyone should be working to end it.'” Moreover religious opponents can have secular reasons for their anti-abortion views.

[109] "Abortion"; InfoFinland; November 28, 2022

[110] "Having an Abortion in Denmark"; City of Copenhagen

[111] Andie Sophia Fontaine; "Iceland's New Abortion Law Goes Into Effect Today"; Reyjavik Grapevine; September 2, 2019

[112] Brian Earp tweet; May 28, 2022

[114] Vanessa McLeod; Instagram post; March 17, 2023

[115] Kassy Dillon; "Massachusetts Democrat told to step down after abortion comments leave parents irate"; Fox News; February 24, 2023. "'Our fear is that if an unqualified sonographer misdiagnoses a heart defect, an organ defect, spina bifida or an encephalopathic defect that becomes a very local issue because our school budget will have to absorb the cost of a child in special education, supplying lots and lots of special services to children who were born with the defect,' [Framingham Democratic Committee chair Michael] Hugo said at the Feb. 7 [city council] meeting." [116] Such expenses could include, for example, the cost for treatment of urinary tract infections, phimosis, balanitis, sexually transmitted diseases, penile cancer, and cervical cancer; as well as costs associated with employees who miss work due to the above conditions.

[117] "Sorry, Not Sorry – Embracing Down Syndrome Globally"; World Forgotten Children Foundation; February 14, 2020 [118] Robin Perrie; "Endless Love: World's longest married couple with Down syndrome celebrate 28th wedding anniversary"; The Sun; September 10, 2020 [119] Meghan Holohan; "Couple with Doen syndrome say being 'honest' keeps their 23-year marriage happy"; NBC Today; March 21, 2018

[120] Omid Jazayeri, Nasim Gojizadeh; "A male Down syndrome with two normal boys: Cytogenetic, paternity and andrological investigations"; Andrologia; April 2020. "any pregnancies in women with Down syndrome produce children both with normal and with trisomy 21, whereas males are infertile. However, Down syndrome males are not always infertile and this is not global. Here we reported a 36-year-old man with proved nonmosaic trisomy 21 fathered two normal boys."

[121] Amy Julia Becker; "True or False: 90% of Babies with Down Syndrome are Aborted?"; Christianity Today; April 13, 2015. "[I]n 2006-2010 these researchers estimate around 5,300 babies were born with Down syndrome annually. During this same time period, approximately 3,100 babies with Down syndrome were selectively aborted each year. Around 800 of those aborted babies would have died before birth, so without selective abortion, the researchers estimate there would be around 7,600 live births with Down syndrome. The reduction rate of babies with Down syndrome in the United States in 2010 was around 30%. In other words, without selective abortion, the number of babies born with Down syndrome in recent years would have been about 30% higher than it actually has been... [T]his study also demonstrates that the majority of [American] women carry babies with Down syndrome to term... Studies have shown that women who receive a prenatal diagnosis of Down syndrome through amniocentesis... generally seek an abortion 90% of the time. Still, the majority of women do not seek diagnostic information about their baby’s chromosomal makeup, and the majority of women do not abort their babies with Down syndrome. It’s possible that they don’t abort simply because they don’t know they are carrying a child with Down syndrome. But it is just as likely that they decide against having that information not out of ignorance but out of a commitment to their baby... When compared to other countries, the United States’ reduction rate is quite low, comparable only also to the Netherlands, where the reduction rate for the population with Down syndrome is around 35%. Australia, by contrast, has a reduction rate of 55%, and the United Kingdom of 48%."

[122] Brian D. Earp; Curriculum Vitae; Brian D. Earp website; updated February 2022

[123] Hugh Young; Facebook post; September 16, 2016

[124] "San Francisco Symposium 2018"; Attorneys for the Rights of the Child; May 31, 2018

[125] Itamar Shatz; "False Equivalence: The Problem with Unreasonable Comparisons"; Effectiviology; January 20, 2020. "False equivalence is a logical fallacy that occurs when someone incorrectly asserts that two or more things are equivalent, simply because they share some characteristics, despite the fact that there are also notable differences between them. For example, a false equivalence is saying that cats and dogs are the same animal, since they’re both mammals and have a tail. False equivalences, which generally exaggerate similarities and ignore important differences, can be used to equate a wide range of things, including individuals, groups, actions, or arguments, either implicitly or explicitly. Accordingly, false equivalences are frequently used in debates on various topics, especially when it comes to suggesting that there is a moral equivalence between two or more things that are being equated."

[126] Brian D. Earp tweet; December 22, 2022

[127] Andie Sophia Fontaine; "Icelanders Sharply Divided Over Possible Child Circumcision Ban"; Reykjavik Grapevine; March 2, 2018

[128] Brian D. Earp; letter to Almenn hegningarlög; February 21, 2018. [pp 39-209] Earp's massive 171-page submission comprised more than 28% of the total volume (598 pages) of public comments reported by the Icelandic legislature.

[129] Lauren Notini and Brian D. Earp; "Should Iceland Ban Circumcision? A Legal and Ethical Analysis"; Journal of Medical Ethics blog; April 22, 2018

[130] Brian D. Earp tweet; February 23, 2021. "Powerful words by David Balashinsky: An Open Letter to Prime Minister Mette Fredericksen in Support of the Citizen Initiative to Establish 18 as the Minimum Age for Non-therapeutic Circumcision in Denmark buff.ly/2MjXMxN"

[131] See also Brian D. Earp tweet; May 6, 2014. "Why Denmark must carry the courage of its convictions on circumcision - News - The Copenhagen Post..."

[132] See for example "Female Genital Mutilation"; World Health Organization; January 31, 2023; "Female genital mutilation is a human rights violation"; Equality Now; "Female Genital Mutilation (FGM)"; National Health Service (U.K.); September 27, 2022 (each page viewed February 4, 2023)




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