Shared with author's permission.

I have a story to share. This is a story about my son. A curly red headed boy who gives the best hugs and has the most delightful giggle. A boy that is madly in love with his brothers and sisters. A boy that I know will forgive me and his daddy for the horrible choice we made on his behalf because that is the kind of heart he has. 

On a glorious autumn morning my sweet son was born into a family full of love in the peaceful surroundings of his parent’s bed. Quinn came into the world with much to say and introduced himself in a very boisterous way. The peace and tranquility ended on day 16 of his life. On that day, the tears and hurt began. 

My husband and I took Quinn to have his circumcision performed at the office of a recommended urologist. We naively believed that this was “just a routine procedure”. My husband filled out the paperwork while I nursed Quinn in the waiting room. We were called back and asked if we wanted to stay in the room while the doctor did the procedure. We both wanted to be there for him and I wanted to be able to nurse him for comfort right away. Quinn was strapped down and the doctor numbed his penis. He screamed in pain and I felt my stomach drop. A few minutes later the doctor did the cut and the nurse commented, “That’s a beauty.” The doctor invited my husband to take a look seemingly proud of what he had just done. We were told to put Vaseline dressings on at each diaper change and dismissed to go home. I again nursed my little man and then buckled him into the car seat. Quinn cried for a few minutes and then fell asleep from the intense stress of it all.

When we arrived home we were greeted by my mom and Quinn’s big brother and sister. We cuddled on the sofa for a little bit and then my mom took Quinn into my room to change his diaper before we sat down to dinner. I heard my mom yell for me in a frantic voice. I rushed in to see what was alarming her and was shocked to see Quinn had bled through his cloth diaper and the diaper cover. There was a lot of blood and it was still oozing out of the circumcision site. I yelled for my husband to call the doctor right away. It was now about 5:45 pm so when he called the doctor’s office no one answered. I insisted he keep trying and then attempted to call myself 3 times. When it became clear we would not get through to the doctor I called Quinn’s pediatrician. He instructed us to apply very firm pressure to his penis for 10 minutes and if the bleeding did not stop to go to the emergency room. After 10 minutes it was clear that this was not going to be enough to subside the bleeding. We jumped in the van and rushed to the emergency room. By the time we got to the ER Quinn had lost a lot more blood. I was holding him in the waiting room and my jeans were soaked with his blood, the blanket I had wrapped him in was soaked with blood, his little socks were soaked with blood. When we arrived they assessed the situation and asked us why we had not called the urologist. We informed them we could not reach him. My husband continued to hold firm pressure on Quinn’s penis while the ER staff decided what to do. They were able to contact the urologist and decided to use a liquid to try to stop the bleeding. The ER doctor told us it had a 50/50 chance of working. The bleeding slowed down for a few minutes and then picked up again. The bed and the towels on the bed became saturated with Quinn’s blood. My husband and a paramedic in training held pressure to Quinn’s penis while we waited for an ambulance to transfer us to the ER where the urologist who did this to Quinn had privileges. It seems we chose the wrong ER unknowingly since we were not told what to do in the event of an emergency. The urologist on call at the ER we originally went to refused to fix the mistake of another doctor. The ambulance crew arrived and was instructed that it was necessary to continue to apply pressure to Quinn’s penis to slow the bleeding. The EMT that would be sitting in the back of the ambulance with Quinn and me insisted that I buckle him into his car seat rather than hold him in my arms on the stretcher. Against my instincts I complied. When we got situated in the back of the ambulance the driver turned on the lights and began to drive quickly to the next ER. The EMT in the back said “You can kill all that.” At which time the driver turned off the lights and began driving the speed limit. Inside I was screaming “What? No, we need to get there quickly.” But, I thought the EMT knew best since he was the medical professional. I was sitting next to Quinn’s car seat and keeping a close eye on him. I commented that he was bleeding through the towels and the EMT came over to take a look then sat back down. A few minutes later I repeated that he was losing more blood and was answered with, “Mmm.” I then questioned why Quinn was looking so pale and why his lips were turning blue. The EMT responded “There could be a lot of reasons for that.” Again I dumbly trusted the medical professional. I assumed we were safe because we were in the back of an ambulance. During the 45 minute drive to the ER (which could have been less than 20 minutes had the driver left the lights on and gone fast) I continued to comment on Quinn’s blood loss and color. The EMT only checked the monitor for oxygen levels. When we finally arrived at the next ER the paramedic on duty there took one look at Quinn and said “His color is awful. We need to get an IV in this baby right away.” They put in the IV and placed an oxygen mask on my baby’s face. I was terrified. My husband and I were both sobbing and stood there holding onto one another and asking God to “Please spare our son. “ I looked down to see his car seat full of blood. We felt completely helpless and so guilty that our baby had to endure this. The urologist that had performed the circumcision came in and placed four sutures in Quinn’s penis. He had cut the frenula artery when performing the original surgery. The bleeding finally stopped. The ER staff then drew some blood to run Quinn’s hemoglobin and hematocrit levels. They came back low but not low enough to warrant a blood transfusion so we were monitored for a couple of hours then sent home. We were told to have the blood work done again the next day. I did not want to cause Quinn extra stress so I asked my midwife to please come to the house to take his blood rather than driving him back to the lab. She agreed and said she would drive the blood right to the hospital for testing. When she arrived, she checked his heart rate and breathing and drew the blood. She left and on the way to the hospital she called Quinn’s pediatrician to discuss his condition. She then called me and informed me that they both agreed that due to his rapid heart rate and breathing as well as his listless state that I needed to call 911 right away and go back to the ER with Quinn. I did just that and this time had an amazing ambulance crew. My midwife was at the ER waiting for us with the lab results that Quinn’s hemoglobin and hematocrit had dropped dramatically since the night before. The ER wanted to run their own test so Quinn was poked again. The results came back the same. We were then sent by ambulance to a hospital with a pediatric unit.

We were admitted to the hospital and spent 23 hours there being observed. His levels were checked at 5:00 am the next morning and were on the rise so he did not require a blood transfusion. We had to stay until 8:00pm that night because he was still very lethargic and nursing poorly. He lost 5 ounces and needed to show the doctors that he could eat well before we could go home. The next two weeks we had follow up appointments and more blood work to make sure Quinn’s hemoglobin and hematocrit
continued to rise. He has to take iron supplements until his levels are normal again. All of this because we believed the LIE that circumcision is “just a simple procedure.” During the time our son was meant to learn that his world is a safe and loving place, he had to endure needless pain. Please consider what happened to Quinn before you decide to have your son circumcised. I believe Quinn is alive today because my midwife let his cord pulse. He had that extra blood in his little body and it acted as his safety net. Our family was blessed with another son 15 months after Quinn’s birth. Ezra remains intact as will any future sons.

Written by: Teri Mitchell, RNC, BSN, LCCE, IBCLC, SNM Questions? teri_mitchell@baylor.edu

The aim of this paper is to critically appraise a meta-analysis examining the relationship between circumcision and prevention of HIV acquisition in heterosexual males. Due to the highly personal nature of circumcision as an intervention, there are few randomized controlled trials (RCTs). However, results from three African RCTs were published between 2005 and 2007 (as cited in Mills, Cooper, Anema, & Guyatt, 2008). Mills et al. (2008) published the first meta-analysis examining the combined results of the three RCTs. The article will be appraised using Melnyk and Fineout-Overholt’s (2010) “Rapid Critical Appraisal Questions for Systematic Reviews” (p. 123). 

            Mills et al. (2008) reported that two-thirds of the world’s 33 million people with HIV/AIDS are native to Africa, specifically in the sub-Saharan region. Given the devastating nature of HIV/AIDS, the sexual mode of transmission, and a cultural belief that condom use equates mistrust (Ko, et al., 2010), there is great need to prevent new cases of infection in Africa, on a large scale (World Health Organization [WHO], 2007). Researchers believe that male circumcision may be one method of slowing the transmission (WHO, 2007).

Validity

            The studies included in the meta-analysis were all RCTs examining the acquisition of HIV among heterosexual males in Africa. The authors provided a description of the systematic approach taken to compile the evidence. Mills et al. (2008) conducted searches of three databases: MedLine, EMBASE, and CINAHL. They also searched two trial registries (clinicaltrials.gov and metaregister) for ongoing and unpublished trials, conference websites, and contacted researchers directly. The authors did not disclose what data was gathered from the researchers. A description of key search terms, years, and language restrictions were not disclosed. There is the possibility of bias if the language was restricted to English language only and if there are other unpublished trials that were not listed with the registries searched.

            The inclusion criteria “included any randomized controlled trial assessing male circumcision to prevent heterosexually acquired HIV infection among males” (Mills et al., 2008, p.332-3). Three trials were identified as meeting this criterion. There was no discussion of whether or not there were any other studies that were identified and later excluded (Mills et al., 2008). No exclusion criterion was included in the article.

            The article reports that the authors examined and compared “methods of allocation concealment, randomization, and adherence to the intention-to-treat principle” (Mills et al., 2008, p.333). However, they did not provide explanation of the variances, if any, between the three trials. The quality and validity of the individual studies was not discussed prior to discussion of pooled data. There was also no discussion of disagreements between researchers or how they were resolved, if present (Mills et al., 2008). The results across the three studies were consistent. In fact, all three studies ended early because the intervention had proved effective. Data from individual trial participants was not discussed, other than that participants who tested positive for HIV at the onset of the study were excluded from this analysis. A compilation of the data from all three trials was appropriately combined, considering that all trials measured the outcome of interest for this meta-analysis (Mills et al., 2008). The DerSimonian-Laird random effects model was used to combine the outcomes of all the RCTs (Mills et al., 2008). The DerSimonian-Laird random effects model “accounts for the heterogeneity of studies through a statistical parameter representing the inter-study variation” (DerSimonian & Kacker, 2007, p. 105).

Results

            The outcome of interest was the number of men who seroconverted to HIV positive during the two year study timeframe. The pooled data concluded that men who undergo circumcision are 56% less likely to serocovert to HIV positive (RR 0.44) than men who are not circumcised. It is statistically unlikely that the results occurred by chance with a p-value of p<0.0001.  The effect size was not reported. The number needed to treat (NNT) was reported as 72.  This can be interpreted to mean that in a HIV endemic region, 72 circumcisions would need to be performed before one case of HIV is prevented in two years (Mills et al., 2008).

            A forest plot was included in the meta-analysis that showed consistency and homogeneity among the three trials. The confidence intervals (CI) were rather narrow, with a combined CI 0.33-0.60. CIs from each of the studies were less than 1.0, indicating that the researcher can conclude with 95% confidence that there is a significant difference between the intervention group (circumcision) and the control group (intact foreskin). This provides the clinician with knowledge that the numerical findings are precise and reliable. It is likely that the results may be repeated by other researchers, with a similar population (Mills et al., 2008).  

            As mentioned previously, all three of the trials were stopped early. Mills et al. (2008) reported that stopping the trial early most likely exaggerated the effects of the intervention. The authors go on to say that the results may not be repeated with large scale application, in the absence of controls and sex education. Furthermore, Mills et al. (2008) offer that failure to abstain from intercourse during the six week post-operative healing period may actually increase the odds of HIV transmission. Finally, the authors included a discussion of a study from Uganda that demonstrated a false sense of protection offered by circumcision which may actually increase HIV transmission by increased high-risk sex behaviors (as cited in Mills et al., 2008). While the numerical values are impressive, the clinical reliability of the intervention must be interpreted with caution. 

Applicability to Practice

            The only similarity between the subjects in this meta-analysis and my patients is male sex. The subjects in the meta-analysis were adult males living in a HIV endemic region in Sub-Saharan region of Africa (Mills et al., 2008), where condom use is infrequent (Ko, et al., 2010), and clean water is not widely available. My clients are newborn baby boys, not sexually active, living in American suburban middle class cities, with excellent access to medical care, clean water, and a culture that encourages condom use and safe sexual practices as the child matures into a man.

Circumcision is already widely available in my practice area. Parents who choose newborn circumcision for their child can typically procure the procedure with minimal effort. The vast majority of insurance companies in the state of Texas cover the cost of the procedure, including public insurance plans. It is very feasible to implement this intervention in my practice setting.

The meta-analysis did not discuss the risks of the procedure, beyond the risk of falsely believing that the intervention would offer complete protection from HIV acquisition. A review of the literature on circumcision complication reveals that complications include bleeding, infection, glans amputation, meatal stenosis, need for further surgery (Weiss, Larke, Halperin, & Schenker, 2010), lack of informed consent, male and female sexual dysfunction (Boyle, Goldman, Svoboda, & Fernandez, 2002; Perera, Bridgewater, Thavaneswaran, & Maddern, 2009), and death (Center for Disease Control and Prevention, 2012). Advertised benefits of the intervention include a decreased risk of sexually transmitted infections and fewer urinary tract infections in the first year of life (American Academy of Pediatrics, 2012).

The results of the trials examined in this meta-analysis contribute to the body of evidence related to circumcision as an intervention. It is suggestive of the potential to offer a decreased rate of HIV acquisition in two years following surgery in adult heterosexual males (Mills et al., 2008). Further research must be done on the long term outcomes of the intervention. Are the rates of HIV seroconversion significantly different at 5 years, 10 years, and 20 years following circumcision, as compared to the control group? How many of the men acquired HIV in the six months before the onset of the study, but seroconverted during the study period? Are the rates of HIV significantly lower among males who were circumcised before their sexual debut, than males who were never circumcised? What is the NNT in regions that are not endemic for HIV, where clean water is readily available for hygiene, and condoms are widely available and culturally accepted? These are all questions that the literature would need to provide before I would begin recommending this intervention in my clinical setting. Until then, my clinical expertise leads me to the conclusion that the sexual practices of adult men in the developing world have little in common with newborn baby boys in an American suburb.

Culture, religion, tradition, and the preferences of the parents are major contributing factors in the decision to circumcise in America. Circumcision is a very personal decision. Some people believe that a personal decision means that the parents decide on behalf of the child. Others believe that a personal decision means that the child should decide for himself, once he is old enough to understand the implications. This meta-analysis certainly has a place in the discussion with an adult man who is deciding whether or not to undergo the intervention, has a full understanding of the function of the body part being removed, and the risks involved. However, the findings of this study are not applicable to a newborn baby boy who is many years from sexual maturity, in a region where other less invasive and more ethically acceptable methods are available to prevent transmission. While parents may consider other cultural, religious, traditional, or health reasons for choosing to circumcise their baby boy, this is not typically one of them, in my clinical experience. 

Conclusion

            Mills et al. (2008) performed the first meta-analysis of the three African RCTs examining the relationship between circumcision and heterosexual acquisition of HIV. The meta-analysis concluded that circumcision reduces HIV transmission by 56% (Mills et al., 2008). The statistical results are impressive and contribute to the body of evidence regarding HIV transmission. The results must be interpreted with caution because of several limitations of the trials that may have inflated the effectiveness of the interventions. Further research is needed to evaluate the long term effectiveness of the intervention when applied to a larger population and lacking stringent research controls. The trials had several threats to external validity, and applicability to men outside of the sample must be studied further. Based on this meta-analysis alone, the evidence is not reliable enough to recommend infant circumcision as a method preventing HIV acquisition.

References

American Academy of Pediatrics (2012). Circumcision policy statement [Policy Statement]. Pediatrics, 130 (3). doi:10.1542/peds.2012-1989

Boyle, G.J., Goldman, R., Svoboda, J.S., Fernandez, E., (2002). Male circumcision: Pain, trauma, and psychosexual sequelae. Journal of Health Psychology, 7(3), 329-343. doi: 10.1177/135910530200700310

Center for Disease Control and Prevention (2012). Neonatal herpes simplex virus infection following Jewish ritual circumsions that included direct orogential suction- New York City, 2000-2011. Morbidity and Mortality Weekly Report, 61(22), 405-409. Retrieved from http://www.cdc.gov/mmwr/pdf/wk/mm6122.pdf

DerSimonian, R., & Kacker, R., (2007). Random-effects model for meta-analysis of clinical trials: An update. Contemporary Clinical Trials, 28, 105-114. Retrieved from http://www.niaid.nih.gov/about/organization/dcr/BRB/Documents/sdarticle.pdf

Ko, I., You, M., Kim, E., Lee, T., Kim, S., Kim, Y., Lee, H.K. (2010). Family planning practice and related factors of married women in Ethiopia. International Nursing Review, 57(3), 377-382. doi:10.1111/j.1466-7657.2010.00805.x

Melnyk, B. M. & Fineout-Overholt, E. (2010). Evidenced-based practice in nursing and healthcare: a guide to best practice (second edition). Philadelphia: Lippincott Williams & Wilkins.

Mills, E., Cooper, C., Anema, A., & Guyatt, G., (2008). Male circumcision for the prevention of heterosexually acquired HIV infection: a meta-analysis of randomized controlled trials involving 11050 men. HIV Medicine, 9, 332-335. doi: 10.1111/j.1468-1293.2008.00596.x

Perera, C.L., Bridgewater, F.H.G., Thavaneswaran, P., Maddern, G.J., (2009). Nontherapeutic Male Circumcision: Tackling the difficult issues. International Society for Sexual Medicine 6, 2237-2243. DOI: 10.1111/j.1743-6109.2009.01306.x

Weiss, H., Larke, N., Halperin, D., & Schenker, I., (2010). Complications of circumcision in male neonates, infants, and children: a systematic review. BMC Urology 10(2). Retrieved from http://www.biomedcentral.com/1471-2490/10/2

World Health Organization (2007). WHO and UNAIDS announce recommendations from expert meeting on male circumcision for HIV prevention [Press Release]. Retrieved from http://data.unaids.org/pub/pressrelease/2007/20070328_pr_mc_recommendations_en.pdf

So your doctor has told you that not enough foreskin was removed during your son’s circumcision. A circumcision revision surgery or “recircumcision” has been recommended. As a parent, you love your son and you just want what’s best for him. You may be asking yourself, is this surgery really necessary? Warning: clicking hyperlinks in this article may take you to nude images. Please click carefully.

For many years, doctors were performing what is known as a "high and tight" circumcision. After the procedure, all of the baby's foreskin was gone and the glans fully exposed, leaving an end result that looked very much like a circumcised adult.

The problem though was that the removal of that much skin was causing complications. Children with high and tight circumcisions were growing up without having enough mobile penile skin to comfortably accommodate erections. So they were experiencing complications such as:

-tight painful erections, 
-penis wildly curving to one side,
-chafing and tearing of the circumcision scar tissue, and
-scrotal skin pulled up onto the shaft of the penis resulting in "hairy shaft".

All of these problems are the result of having too much skin being removed. After a circumcision revision surgery, a child may indeed look more “like daddy” but he is also subject to all of the above complications that come with having a tight circumcision. These complications not only lead to a great deal of discomfort for the circumcised man, but also for his sexual partner(s). Men experiencing these issues can find some relief from stretching the remaining skin using non-surgical foreskin restoration techniques. Foreskin restoration is painless but it is a slow, arduous process to undergo. 

Knowing what we now know about the complications of high and tight circumcisions, many doctors today are doing what is called a "loose circumcision", where more of the foreskin is left behind for the child to grow into. Sometimes initially this makes the child look like he isn't really circumcised, but with time and recession of the fat pad the child grows into the remaining tissue and eventually realizes the expected aesthetic effect of circumcision. 

Unfortunately not all doctors are aware of the shift towards the loose circumcision. Upon encountering a child with today’s loose circumcision, an uninformed doctor may pressure the child’s parents to "revise" something that requires no revision whatsoever. This is why we are seeing a sharp increase in circumcision revision surgeries at this time. Again, these surgeries are overwhelmingly unnecessary and are a result of doctors who are uninformed on this issue.

Risks Associated With Circumcision Revision Surgeries

Because circumcision revision surgery is strictly cosmetic (not medically needed for the health of the child), any complications of the surgery are 100% avoidable by simply not opting for the procedure. Learn more about the lifelong complications caused by circumcisions and circumcision revisions here (graphic):

-Gallery of Botched Circumcisions
-Circumstitions: Complications of Circumcision
-Global Survey of Circumcision Harm: Photo Gallery of Damage
-Historical Medical Quotes on Circumcision: Circumcision Complications

In addition to complications of the circumcision surgery itself, there are also many concerns that go with use of general anesthesia in infants and children. "Examples of side effects are nausea, vomiting, drowsiness, dizziness, sore throat, shivering, aches and pains, discomfort during injection of drugs, and agitation upon awakening from anesthesia... Adverse effects... may include dental trauma, croup (swelling of the windpipe), allergic reactions to drugs or latex products, wheezing, vocal cord spasm or injury, regurgitation of stomach contents with subsequent aspiration pneumonia, injury to arteries, veins or nerves, alterations in blood pressure, and/or irregular heart rhythms. Death and brain damage are the most feared of all anesthetic risks, but fortunately these complications are extremely rare." (Source: Society for Pediatric Anesthesia)

Questionable Motives of Doctors Recommending Recirumcision

A recent study has revealed that surgical repairs are big business for hospitals. In 2010, an unnamed, nonprofit 12-hospital chain in the southern U.S. was paid more than double when treating surgical patients who had complications compared to those who only underwent the initial surgery. There is zero profit to be made in a child that requires no further surgical modification, however there is great profit to be made in convincing parents that their child needs further surgical modification to his penis after the initial circumcision. Which leads you to wonder: are medical professionals looking at your son's loose circumcision and seeing dollar signs?

Common Questions Regarding Loose Circumcision

My son’s foreskin is "growing back", covering the head of the penis, stuck, adhered. Won't he have problems if it's not removed?
A naturally intact boy’s foreskin is fused to the head of the penis the same way your fingernail is fused to your finger. Sometimes after a circumcision, the remaining foreskin will adhere back on to the glans in an attempt to heal itself, causing what are called penile adhesions. This is very common. In this situation, we advise parents to just leave the foreskin alone and only clean the outside of it, the same way you would care for an intact boy. Some doctors may insist that the foreskin needs to be removed altogether or at the very least ripped back. This is a harmful act, causing severe pain to the child, bleeding, possible infection, and scarring. Do not allow doctors or other medical professionals to rip the foreskin remnant back if it has readhered. The adhesions will likely break down on their own over time, as they would with an intact child. If they don’t, less invasive procedures can aid the process along. In most cases, surgery is not needed.

But my son doesn’t look circumcised. Won’t he wonder why he doesn't look like daddy?
Neonatal circumcision techniques and results vary greatly because each patient is different, each doctor is different, and there are different circumcision methods utilized. So it’s already likely that no two circumcisions are ever going to look exactly alike. Your son is more likely to notice differences in size or body hair than the appearance of the penis. If he does ask, you can easily explain that there’s nothing wrong, just that dad had a surgery that resulted in his penis looking different from son’s. 

What if other kids make fun of him for not looking circumcised?
Today, the circumcision rate in the United States is roughly 50/50. That means about half of your son’s classmates will be intact and about half of them will be circumcised, and among them all will have varying lengths of foreskin. Your son will not be the odd man out. If bullying is an issue, any incidents should be reported to school authorities so those doing the bullying can be dealt with accordingly. Surgery is not needed.

My doctor said the recircumcision needs to be done. If the doctor said so, he must need it. Right?
Not necessarily. Doctors are human; they do make mistakes. America doctors used to actually recommend cigarettes to their patients. Now it’s common knowledge that cigarettes make you sick and can kill you. Hindsight is always 20/20. That’s why we recommend getting second and third opinions before proceeding with an irreversible surgery. Here’s a list of doctors who may be able to help you.

I'm planning on getting my son circumcised. Should I request a loose circumcision? 
The male foreskin is a highly specialized organ with a number of protective and sexual functions. It is literally the most sensitive part of the penis. Knowing this, there is no such thing as having too little foreskin removed, but there is most certainly such a thing as having too much removed. In other words, the more foreskin a child is left with, the better. 

All circumcision surgeries include risk. Regardless of the amount of tissue removed, you might still be expected to encounter meatal stenosis, skin tags, skin bridges, excessive scarring, MRSA infections, even death as a complication of routine circumcision. For these reasons and others, many parents are choosing not to circumcise their infant sons noawadays. To learn more about circumcision, check out this article written by The WHOLE Network's founder about her own journey of discovery when she was pregnant with her first son. Then go to our website's library to continue your search.

On July 18, 2012, Russell Brand told Howard Stern exactly how he feels about circumcision and answered questions about his own intact penis on The Howard Stern Show. Read a transcript of the conversation and watch the video. 

Howard Stern: Are you circumcised Russell because a lot of British guys aren't. 

Russell Brand: No we don't do it in England. It's just more like, people don't worry about it. They just, they just let it go, that sort of thing. 

Howard Stern: I approve of that. Yeah I approve of that. I don't think God meant us to lose a part of our penis. 

Russell Brand: Yeah what's the point? It's a bit unfair, isn't it, to do that to babies? I mean, you're alive a little while, start chopping bits of his dick off. I don't think God cares about that. He's got a lot on.

Howard Stern: Do you have any trouble with your penis in terms of um, like they say the smegma and all this kind of stuff?

Russell Brand: No no no you've got to look after that fellow. No no he's in great shape, thank you very much for asking.

Howard Stern: Do any of these American girls freak out because you're uncircumcised? 

Russell Brand: They seem very grateful to be honest. 

Howard Stern: Really?

Russell Brand: Well yeah of course they do. They're havin' the time of their lives. They can't start complaining about religious ceremonies. They're in the throes of ecstasy!

 Just published in Haaretz in Israel.
 It is an amputation of a healthy, sensitive body part that is performed without specific medical need, and without the patient's consent.

By Victor S. Schonfeld

Germany's parliament may soon approve a law to protect religious circumcision, this to counteract a Cologne court ruling last June that pronounced the practice unlawful.

This is wrong - the German government should rethink. I say this as a Jewish parent from a proud rabbinic lineage, with relatives killed in the Holocaust; I say this as the maker of "It's a Boy!" - the 1995 British TV documentary that first broke the taboo on showing the hidden toll of circumcision. It demonstrated how a rite ingrained in Jewish and Muslim culture, and said to be divinely commanded, regularly results in acute suffering, injuries, mutilation and deaths.

The film triggered a furor in Britain by chronicling the near-death of a baby circumcised by a mohel, and I hoped this would start a phasing-out of the custom. Instead, at pulpits across the U.K., rabbis denounced "that film made by a self-hating Jew," and urged parents to ignore it.

Change in the community could not come on the strength of information alone; I saw that government involvement would be needed. It was especially disappointing because my Jewishness prizes dissent and open debate.

Now my 12-year-old daughter is looking forward to her bat mitzvah, and she hears that Israel's Chief Rabbi Yona Metzger has declared circumcision is "the root of the Jewish soul." "An amputation done with no pain control?" she says. "Done outside of hospitals, by people who are not doctors? A religious ritual only for boys? How can this be the root of the Jewish soul in 2012?"

Sadly, I explain that there is enforced ignorance, as was the case when our family was pressured into having her older brother circumcised as an infant. Only after we witnessed his agony did we realize we'd been bullied into betraying our protective roles. I explain that injuries and near-deaths are hushed up, though each day hundreds of such incidents occur globally among those who practice the rite (as research by the British organization NORM-UK reveals ). I explain that fatalities are rarely spoken of, though each day brings three or four. And the lost children have sometimes been erased from Jewish family trees, as my film attests. That can be comprehended perhaps as a legacy of the Talmud, which instructs that a mother may cease offering babies for circumcision after three of her offspring have died from it.

I recall the TV documentary I made against corporal punishment of children, and how I applauded countries like Israel and Germany, which were among the first to outlaw such punishment. It appears to me wholly contradictory that those countries protect a tradition that routinely inflicts greater suffering and harm. And none should take a lead from America, where it's still legal for parents to hit children, where pediatricians profit from a sideline in circumcisions of boys of all backgrounds. The American Academy of Pediatrics, the profession's trade organization, has issued yet another equivocal statement recently, about a practice that is a money-spinner for some of its members.

The Cologne court was right to rule that circumcision is an assault on a child. It is an amputation of a healthy, sensitive body part that is performed without specific medical need, without the patient's consent. Elected leaders of conscience should not support a custom that so obviously infringes principles enshrined in the United Nations Convention on the Rights of the Child.

In Israel, some young adults now choose to be tattooed with the Auschwitz numbers of their forbears. A moving tribute. But if a religious leader decided it was God's commandment that babies be tattooed, we'd halt that everywhere. Religious Jews manage without animal sacrifices, without polygamy, without a range of practices that enlightened rabbis found reasons to dispense with over the centuries.

Ironically, there was a time in Germany, long before the Nazi era, when some rabbinic leaders advocated abandoning circumcision; they termed it barbarism. Theodor Herzl, the father of Zionism, refused to have his son circumcised.

Given present knowledge of the pain and complications caused, an absolute ban is logical. But a sudden ban could drive circumcision underground. The law now should require that circumcision is only performed by doctors, in hospitals, using effective anesthesia, after both parents have been fully apprised of the risks. This will substantially reduce the prevalence of the custom, and will reduce the casualty rate and the suffering. With phased steps toward abolition, proponents of religious circumcision may put up less of a fight as the practice gradually falls out of favor.

I think about this positively: For my daughter's generation and those following, shouldn't Jewish and Muslim identities embrace children's rights? Nonviolent welcoming ceremonies would be equally meaningful for baby girls and boys. A handful of rabbis in America and Germany have been pioneering "brit shalom" ceremonies. These celebrate the perfection present at the birth of all children. That's the true praise for a Creator, after all, rather than "corrective surgery" for every newborn boy.

Despite Wednesday's decision by the German cabinet to approve legislation that would protect circumcision, it's still not too late to reverse course. In a letter I've sent Chancellor Angela Merkel my message is simple: Please don't undo the opportunity for change created by your courageous Cologne judge. Jewish and Muslim children deserve protection from a hurtful, dangerous custom overdue for replacement. If it takes a court in 21st-century Germany to help us move beyond circumcision, I welcome that.

Filmmaker Victor Schonfeld's documentaries include "Loving Smacks," "Shattered Dreams: Picking Up the Pieces" and "The Animals Film." "It's a Boy!" is available from www.itsaboythefilm.com.

 http://www.haaretz.com/print-edition/opinion/an-end-to-the-agony.premium-1.469576

-- American Rabbis Explain their Opposition to Circumcision.
Progressive Rabbis On Creating A Jewish Covenant Without Circumcision
Humanistic Judaism Increasingly Critical of Child Circumcision
Rabbi Nathan Segal * A Progressive Rabbi urges us to move to peaceful covenants.
Rabbi Jeffrey Falick: Eliminating The Cruelest Cut * The Vice President of the Association of Humanistic Rabbis writes on Intactivism.
Rabbi Jeffrey Falick: A Resource Guide To The "Intactivist" (No Circumcision) Movement *

Jewish Intactivist Media.
BeyondtheBris.com * Jewish Intactivist Articles & Opinions.
Cut: Slicing Through the Myths of Circumcision * A Movie by Orthodox Intactivist, Eliyahu Ungar-Sargon
Questioning Circumcision: A Jewish Perspective by Ronald Goldman, Ph.D. *
Rabbis and other leaders who lead covenant without cutting ceremonies. *

Jewish Intactivist Groups.
Jews Against Circumcision * Jews For the Rights of the Child * Questioning Circumcision: A Jewish Perspective * Gonnen * Kahal * Af-Mila: An Israeli Jewish Intactivist Journal *
The Israeli Association Against Genital Mutilation *

The Moral Problems of Circumcision & the Search for Jewish Alternatives.
Jewish Rationales for Abolishing Circumcision * by Jews Against Circumcision.
Eli Ungar-Sargon & Rabbi Shmuley Boteach on the Ethical Problems of Circumcision * At the Manhattan Jewish Experience.
Eli Ungar-Sargon: Outlawing Circumcision: Good for the Jews? * Published in the Jewish Daily Forward.
Hebrew Scholar Vadim Cherny: How Judaic is circumcision? * It’s not at all, he finds.
Circumcision Questions (letter from an intact Jew). * Published in the Northern California Jewish Bulletin.
Miriam Pollack: Circumcision: Identity, Gender, and Power * Originally published in Tikkun magazine.
Miriam Pollack: Circumcision : A Jewish Feminist Perspective * Published in Jewish Women Speak Out.
The Measure of His Grief by Lisa Braver Moss * A new book exploring Jewish intactivism
Jenny Goodman, MD: An Alternative Perspective * A Jewish doctor in the UK urges us to keep our sons intact.
A Jewish Case for Bris without Milah. *
Moshe Rothenberg: Being Rational About Circumcision and Jewish Observance *
Brit Milah: Inconsistent with Jewish Ethics? * Written by a Jewish parent. The Foreskin and Human Rights Law.
Jewish Questioning of Traditional Circumcision * Part 1.
Jewish Questioning of Traditional Circumcision * Part 2.
Jewish Questioning of Traditional Circumcision * Part 3.

Leaders in the Jewish Movement to Abolish Circumcision

The Intactivist Movement Within Judaism. * Published on Saving Sons
Today’s Jews Reject Circumcision and Choose Peaceful Welcoming Covenants * An Intactivist Midwife.
Regretting Circumcision: Women’s Perspectives * Published on Dr. Ron Goldman’s site.
Progressive, Moral Jews speak out in Favor of Banning Circumcision on Minors. * Intactivism and Human Rights.
The History of Circumcision: Leonard Glick , MD, PhD. explains how he came to write Marked In Your Flesh. *
American Jews Speak Out in Favor of Banning Circumcision on Minors *
International Jews Also Favor Outlawing Circumcision of Minors *
Judaism, Human Rights and the History of Circumcision *

Peaceful Covenant Texts for Jewish Parents.
Worldwide list of Rabbis who lead covenant without cutting ceremonies *
Song for an Intact Jewish Boy’s Welcoming Ceremony *
Brit B'lee Milah Ceremony *
A Brit Shalom Ceremony *
Norm Cohen: A Brit B’lee Milah Ceremony *

Jewish Parents' Experiences Keeping their Sons Intact.
Dear Elijah: A Conservative Jewish Father's Letter to His Intact Son * Published on Peaceful Parenting.
Moshe Rothenberg: Ending Circumcision in the Jewish Community? * Envisioning an Intactivist Judaism.
Michael Kimmel: The Kindest Un-Cut: Feminism, Judaism, and My Son's Foreskin * Published in Tikkun.
The Naming * Published on Very, Very Fine.
Stacey Greenberg: My Son: The Little Jew with a Foreskin * Published in Mothering Magazine.
Intact & Jewish * Published on the Natural Parents Network
Laura Shanley: A Jewish Woman Denounces Circumcision *

 A growing number of Jews are in favor of banning child circumcision. These Jews recognize a minor's right to their own body, a right that supersedes the rights of a parent to harm the body of a child in the name of religion.

The past century has been marked by the declaration and protection of universal human rights, as well as a marked increase in the quality of life, both in the United States and worldwide. With these improvements, higher expectations regarding a child’s right to bodily autonomy have become socially accepted and legally mandated. Many argue that since female children in the U.S. are protected by a 1996 law banning female circumcision, this law should be expanded to include the protection of male children as well.

There are a growing number of Jews who are becoming increasingly vocal in questioning both the ethics and the legality of circumcision. Jews in the Reform Judaism movement have already been advocating for an end to ritual circumcision during the past 180 years. Some forward-thinking Rabbis have created symbolic ceremonies to replace circumcision surgery. The Humanistic Jewish movement only does peaceful welcoming covenants. Already, more than 100 Rabbis from a wide range of Jewish denominations perform symbolic covenant rituals. More and more Jewish and Israeli parents, Rabbis, scholars, and thinkers have come to oppose circumcision.

What follows is a collection of statements from Jews who question the ethics and legality of forced under-age circumcision.

Jewish Americans Support Outlawing Child Circumcision

"I am a Jewish mother against circumcision and in support of passing Bill 1777. For years I was a certified childbirth educator and now a journalist and filmmaker. I continue to educate people that childbirth is a natural event rather than one filled with unnecessary drugs and other medical intervention, and circumcision is an unnatural event. These are two clear-cut examples of interfering with nature."
- Katherine Mora, Jewish Mother , Testimony before the Massachusetts Joint Committee on the Judiciary

“In Massachusetts, two Jewish mothers testified in favor of a law making circumcision illegal. Moreover, several Jews and Jewish organizations throughout the country are backing a proposed national law against circumcision. Jewish groups such as Jews Against Circumcision and the Israeli Association Against Genital Mutilation have endorsed the proposed American MGM bill, which would rewrite the U.S. Female Genital Mutilation Act of 1996 so that boys are also protected from genital mutilation.”
- Questioning circumcision, by Shani McManus and Sergio Carmona, Florida Jewish Journal, June 06, 2011

“Jewish baby boys are human and have rights too, and those rights are violently trampled by his (and my) religion, in the case of brit milah. We must all learn to take the blinders off and somehow stop this heinous practice -- yes, by a law, if necessary.
- Tina Kimmel, PhD, MSW, MPH, Director of NoCirc, East Bay Area
Letter to the Bay Citizen 

“I’d heard how my uncle had fainted during my bris and what a horrible event it was. This was the thing everyone would talk about at the Passover seder… The ban on circumcision that’s on the ballot in San Francisco is a triumph for intactivists… I'm totally for it. San Francisco has often lead the country in elevating our consciousness. It has already helped spread awareness of this human rights crime to other states and hopefully will lead people everywhere to be more compassionate, thoughtful and rational not only towards their own fragile newborn children but to other fellow men and women as well.”
- Jason Paige, Jewish Singer
Blood, Sweat & Tears Lead Singer Protests Infant Circumcision, by Rebecca Wald, J.D., BeyondTheBris.com, July 1, 2011

“The human right to body integrity would, in this instance, override their religious right.…non-fundamentalist Jews, who constitute a very large number of Reform, Conservative, and even some Orthodox Jews, believe that human ethics are an essential element in the Jewish tradition. …there is a Jewish tradition practiced by virtually all Jewish parents today that is morally wrong. This should give pause to any non-fundamentalist religious Jew, and it is a black eye for the liberal movements that they have not taken this issue more seriously. Perhaps a law prohibiting circumcision is just what these Jews need to start a serious discussion about the problem of brit milah.”
- Eli Ungar-Sargon, Outlawing Circumcision: Good for the Jews?, Forward, the Jewish Daily, May 20, 2011

“I happen to agree with you that foreskin removal should be illegal. It is a mutilation… I agree with you that men should not be circumcised. . . I don’t know where this circumcision came from, some people feel it’s a religious thing, it’s about health, it’s about cutting off the foreskin makes your penis less likely to get cancer. There’s been all kinds of myths. I think it’s nonsense. That if you’re born that way, it seems to me it’s a mutilation to cut it off. The same way in Africa they sometimes cut off a woman’s clitoris and they think that’s justified. I think our foreskins were cut off in order to desensitize us, and I think it was a bunch of religious nudnicks who decided they didn’t want us going around fornicating so they cut off some of our penis skin.”
- Howard Stern, Talk Radio Host
Howard Stern, Jewish Intactivist by Rebecca Wald, J.D., BeyondTheBris.com, March 31, 2011

"Laurie Evans, the Jewish director of New York's National Organization of Circumcision Information Resource Centers (NOCIRC), told the Committee that under Jewish law, the son of a Jewish mother is Jewish, whether circumcised or not, and that despite great pressure she had kept her son intact. She said that many Jewish mothers confide to having been horrified by their boy's circumcision ceremony. She said that initially the ceremony involved removing only a small amount of foreskin, not all of it, and that several Jewish organizations recommend a peaceful birth ceremony instead. She urged the panel to watch a circumcision and raised the issue of botched circumcisions. The second Jewish mother to speak, Kathryn Mora, testified she had been devastated that her son was taken from her in the hospital and circumcised without her consent."
- Peter W. Adler, A Bird's Eye View of the Hearing On the Massachusetts Bill to Outlaw Genital Mutilation
Attorneys for the Rights of the Child Newsletter, Summer 2010

International Jews Also Favor Outlawing Child Circumcision

From Israel to the U.K., some Jews feel that circumcision surgery is an outdated tradition, and recognize that it violates many international laws.

“What about religious freedom? Certainly, the ability to freely practise one's religion remains a vital component of any liberal democracy. But should this trump an individual's right to their bodily integrity? And shouldn't such a principle be extended to all those who, by virtue of their age, are too young to decide on which body parts they would or would not like to keep?...
"Article 3 of the European Convention on Human Rights outlaws the kind of "harm" that circumcision can cause; article 14 forbids the discrimination that prevents baby boys from enjoying the same protection of their genitalia as baby girls. In the 21st century, it is time to remember that men, too, can be victims of unjust hegemonic systems tolerated in the name of tradition, culture or religion. If we oppose female genital mutilation, has the time not come for us also to oppose male genital mutiliation?"
- Neil Howard and Rebecca Steinfeld, Time to ban male circumcision?, Guardian UK, June 14, 2011
Rebecca Steinfeld, is a PhD. candidate at Oxford University and has served as an under-35 director and as an associate of the Board of Deputies for New West End Synagogue.

"In Europe today, human rights groups have mounted a grass roots campaign opposing circumcision, comparing it to the brutal mutilation of African women. The Netherlands Institute of Human Rights wants to outlaw Bris Milah. And an article published in the prestigious British Medical Journal (April 2000), written by obstetricians, gynecologists, and midwives from hospitals in France, claimed:
“The [African] women we interviewed considered their daughters’ mutilation and their sons’ circumcision to be similar. Male circumcision is also a form of genital mutilation because it involves removing a healthy part of an organ. How can we convince mothers that they should not mutilate their daughters while they continue to have their sons circumcised?”
A group of Israelis petitioned the Israeli Supreme Court to outlaw circumcision on the grounds that it is criminal assault. Shockingly, this campaign even has adherents in Israel. In February 1998, a group of Israelis petitioned the Israeli Supreme Court to outlaw circumcision on the grounds that it is criminal assault. A joke? No. Case number 5780/98 is a real case, and the court has already held hearings.
Avshalom Zoossmann-Diskin, Executive Director of the Israeli Association Against Genital Mutilation in Tel Aviv, says that a campaign is urgently needed to end Bris Milah. “Why are they discriminating against me as victim of Jewish male genital mutilation?” he decries. “Are my human rights, bodily integrity and suffering less important than those of African girls?!”
- Circumcision: Beautiful or Barbaric? by Rabbi Shraga Simmons.

"As a liberal Jewish woman, I agree 100 per cent with the German court’s decision [to ban circumcision].
Maimonides knew, centuries ago, that circumcision impacted men’s sex drive, making sex and masturbation more difficult and less pleasurable, in addition to leaving penises weaker. According to him, circumcision’s job is to cause pain to boys’ members in order to accomplish the objectives stated above; it’s not about any covenantal accord referred to in scripture at all.
It’s also interesting to note that the first people to be circumcised in the Torah are teens and adults capable of making the decision on their own terms, something that makes sense given a comment in the Talmud that somebody ready for circumcision is akin to a groom.
On first glance, they’re not similar at all, since eight-day-old infants are vulnerable and deserve to be protected from anything unnecessary that can hurt them and grooms are older, capable of independent decision-making.
However, if we return to the Scripture and think about everything in a marriage context, perhaps the similarity is this: if someone ready for circumcision is akin to a groom, he has to be capable of rational decision-making and ready to live with the consequences of his actions. Circumcision will always be a hotly debated topic but in the long run, it, like any genital surgery, deserves to be chosen by the people who have to live with its effect."
- Amy Soule, Hamilton, Circumcision of boys amounts to bodily harm, German court rules (June 27) The Spec.
Amy Soule is a volunteer cantor and a Bris Shalom celebrant in the Reform Judaism movement. She also wrote the essay Parshat Lech L'cha: Why Infant Circumcision in Judaism Isn't Kosher on the website Beyondthebris.com.

“It seems to me that for liberal Jews the choice comes down to this. Do we want to in some way circumscribe the sexual possibilities of our sons by performing a body modification when they are infants so as to bear witness to the covenant? Are there not other ways to bear witness? Are there not other ways to maintain our distinctiveness from the society around us? Despite having circumcised my two sons, the more I think about the issue, the more likely – were I a resident of San Francisco – I would support the referendum.”
- Sandford Borins, Ph.D., The Circumcision Referendum: A Liberal Jewish Perspective
Sandford Borins, Ph.D., is a professor of Management at the University of Toronto.

Jewish Intactivist Media.
BeyondtheBris.com
* Jewish Intactivist Articles & Opinions.
Cut: Slicing Through the Myths of Circumcision
* A Movie by Orthodox Intactivist, Eliyahu Ungar-Sargon
Questioning Circumcision: A Jewish Perspective by Ronald Goldman, Ph.D. *
Rabbis and other leaders who lead covenant without cutting ceremonies. *

Jewish Intactivist Groups.
Jews Against Circumcision * Jews For the Rights of the Child * Questioning Circumcision: A Jewish Perspective by Ron Goldman, PhD. *Gonnen * Kahal * Af-Mila: An Israeli Jewish Intactivist Journal *
The Israeli Association Against Genital Mutilation *

Judaism, the Foreskin and Human Rights Law.
Jewish Questioning of Traditional Circumcision * Part 1.
Jewish Questioning of Traditional Circumcision * Part 2.
Jewish Questioning of Traditional Circumcision * Part 3.

The Moral Problems of Circumcision & the Search for Jewish Alternatives.
Jewish Rationales for Abolishing Circumcision
* by Jews Against Circumcision.
Eli Ungar-Sargon & Rabbi Shmuley Boteach on the Ethical Problems of Circumcision
* At the Manhattan Jewish Experience.
Eli Ungar-Sargon: Outlawing Circumcision: Good for the Jews?
* Published in the Jewish Daily Forward.
Hebrew Scholar Vadim Cherny: How Judaic is circumcision?
* It’s not at all, he finds.
Circumcision Questions (letter from an intact Jew).
* Published in the Northern California Jewish Bulletin.
Miriam Pollack: Circumcision: Identity, Gender, and Power
* Originally published in Tikkun magazine.
Miriam Pollack: Circumcision : A Jewish Feminist Perspective
* Published in Jewish Women Speak Out.
The Measure of His Grief by Lisa Braver Moss
* A new book exploring Jewish intactivism.
Lisa Braver Moss: The Jewish Roots of Anti-Circumcision Arguments *
Jenny Goodman, MD: An Alternative Perspective
* A Jewish doctor in the UK urges us to keep our sons intact.
A Progressive Case for Bris without Milah. *
Moshe Rothenberg: Being Rational About Circumcision and Jewish Observance *
Brit Milah: Inconsistent with Jewish Ethics?
* Written by a Jewish parent.

Leaders in the Jewish Movement to Abolish Circumcision.
Intact America: Profile of Orthodox Intactivist Eliyahu Ungar-Sargon *
Intact America: Profile of Jewish Intactivist Miriam Pollack *
Intact America: Profile of Jewish Scholar and Intactivist Leonard Glick, MD, PhD.
* A Jewish history of circumcision.
The Intactivist Movement Within Judaism.
* Published on Saving Sons.
Jewish mom: Circumcision spiritually wounds
* From a lecture by Miriam Pollack.
Today’s Jews Reject Circumcision and Choose Peaceful Welcoming Covenants *
An Intactivist Midwife.
Regretting Circumcision: Women’s Perspectives
* Published on Dr. Ron Goldman’s site.
Progressive, Moral Jews speak out in Favor of Banning Circumcision on Minors.
* Intactivism and Human Rights.
The History of Circumcision: Leonard Glick , MD, PhD. explains how he came to write Marked In Your Flesh. *
American Jews Speak Out in Favor of Banning Circumcision on Minors *
International Jews Also Favor Outlawing Circumcision of Minors *
Judaism, Human Rights and the History of Circumcision *

Peaceful Covenant Texts for Jewish Parents.
Worldwide list of Rabbis who lead covenant without cutting ceremonies *
Song for an Intact Jewish Boy’s Welcoming Ceremony *
Brit B'lee Milah Ceremony *
A Brit Shalom Ceremony *
Norm Cohen: A Brit B’lee Milah Ceremony *

Jewish Parents' Experiences Keeping their Sons Intact.
Dear Elijah: A Conservative Jewish Father's Letter to His Intact Son
* Published on Peaceful Parenting.
Moshe Rothenberg: Ending Circumcision in the Jewish Community?
* Envisioning an Intactivist Judaism.
Laura Shanley: A Jewish Woman Denounces Circumcision
* A Childbirth educator chooses intact.
Michael Kimmel: The Kindest Un-Cut: Feminism, Judaism, and My Son's Foreskin
* Published in Tikkun.
The Naming
* Published on Very, Very Fine.
Stacey Greenberg: My Son: The Little Jew with a Foreskin
* Published in Mothering Magazine.
Intact & Jewish
* Published on the Natural Parents Network

HUMAN RIGHTS ADVOCATES RESPOND TO THE AMERICAN ACADEMY OF PEDIATRICS’ DISREGARD FOR ETHICS AND THE HIPPOCRATIC OATH WITH THEIR CIRCUMCISION POLICY STATEMENT RELEASED ON MONDAY AUGUST 27, 2012.


The WHOLE Network, a grassroots organization dedicated to providing accurate information about circumcision, acknowledges the individual’s right to bodily autonomy. Therefore we find that the only acceptable circumcision policy statement would be one that guarantees that right to the patient in the absence of medical necessity. When performed on a non-consenting minor, routine male infant circumcision violates medical ethics and ignores the first principle of the Hippocratic Oath: First, do no harm.

The last policy statement issued by the AAP in 1999 and reaffirmed in 2007 acknowledges that the modest potential benefits of circumcision do not outweigh the risks. The 2012 statement from the AAP asserts that the benefits of infant circumcision outweigh the risks of the procedure, and that all families should be allowed the option of circumcising infant sons. By suggesting the decision is best left in the hands of the parents, the AAP ignores the ethical dilemma of the leaving the patient out of this decision when he is the person who has to live with the irreversible consequences of the procedure.

Citing evidence from three studies in Africa that found a reduced rate of HIV transmission to circumcised males, the AAP has irresponsibly dismissed conflicting evidence that distinctly calls the effectiveness of circumcision on HIV rates into question.[1-4] The AAP also cites a reduction in urinary tract infections, even though the circumcision procedure itself can cause life-threatening infection.[5-7] Reduced risk of penile cancer is touted, but this cancer is so rare a man is more likely to experience breast cancer[8] than cancer of the penis in his lifetime.[9] The AAP fails to acknowledge that easier, less-costly, non-invasive measures exist for all of the supposed benefits of circumcision, such as condoms, antibiotics, and proper hygeine.

Further, the AAP has turned a blind eye to mounting evidence that circumcision is a harmful practice with serious risks such as hemorrhage [10-19], accidental dismemberment,[20-36] and death,[37-46] and potential life-long physical, psychological,[47-57] and sexual consequences ranging from a personality disorder to erectile dysfunction to orgasm difficulties, with sexual side-effects also extending to his partner.[58]

It is important to remember that the task force charged with reviewing and updating the academy’s position on circumcision is not without conflict of interest. The AAP is a professional organization, which exists to represent and support the professional interests of its members. In its last position statement they acknowledged that those members stand to lose an estimated $150-270 million dollars if circumcisions were no longer performed, without including follow-up care and corrective procedures, which are quite common.[59] The new statement proclaims, "Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it, and to warrant third-party payment for circumcision of male newborns," revealing whose interests they truly have in mind.

Last year when the AAP issued a call to allow physicians to offer a ‘ritual nick’ on the genitals of girls,[60] the immediate and intense public response led to a prompt retraction. The WHOLE Network calls upon the AAP to act quickly to retract the 2012 circumcision statement, and instead put the rights and well-being of the patient before all other interests by condemning routine infant circumcision.

For more information, please visit www.wholenetwork.org

References

1. Brewer D. Scarification and male circumcision associated with HIV infection in Mozambican children and youth. Webmedcentral 2011;2(9):WMC002206.

2. Darby, R. L., & Van Howe, R. S. (2011). Not a surgical vaccine: there is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia. Australian and New Zealand Journal of Public Health, 35, 459-465.

3. Green, L. et al., "Male Circumcision and HIV Prevention: Insufficient Evidence and Neglected External Validity," American Journal of Preventive Medicine 39 (2010): 479-82.

4. Thomas AG, Bakhireva LN, Brodine SK, Shaffer RA Prevalence of male circumcision and its association with HIV and sexually transmitted infections in a U.S. navy population. Abstract no. TuPeC4861. Presented at the XV International AIDS Conference, Bangkok, Thailand, July 11-16, 2004.

5. Bliss Jr DP. Healey PJ, Waldhausen JHT. Necrotizing fasciitis after Plastibell circumcision. J Pediatrics 1997;31:459-62.

6. Cook J, Parish JA, Shooter RA: Acquisition of Staphylococcus aureus by newborn babies in a hospital maternity department. Br Med J 1938;1:74-8.

7. Hurst V. Transmission of hospital staphylococci among newborn infants. Pediatrics 1960;25:204-14.

8. "What Are the Key Statistics about Breast Cancer in Men?" What Are the Key Statistics about Breast Cancer in Men? N.p., n.d. Web. 23 Aug. 2012. <http://www.cancer.org/Cancer/BreastCancerinMen/DetailedGuide/breast-cancer-in-men-key-statistics>.

9. "What Are the Key Statistics about Penile Cancer?" What Are the Key Statistics about Penile Cancer? N.p., n.d. Web. 23 Aug. 2012. <http://www.cancer.org/Cancer/PenileCancer/DetailedGuide/penile-cancer-key-statistics>.

10. Shulman J, Ben-hur N, Neuman Z. Surgical complications of circumcision. Am J Dis Child 1964; 107:149-54.

11. Patel H. The problem of routine infant circumcision. Can. Med. Assoc. J 95 (Sept 10, 1966): 576-581.

12. Gee WF, Ansell, NF. Neonatal circumcision: a ten year overview; with comparison of the Gomco clamp and the Plastibell device. Pediatrics 1976; 58: 824-7.

13. Kaplan GW. Complications of circumcision. Urol Clin N Amer 1983;10:543-549.

14. Griffiths DM. Atwell JD. Freeman NV. A prospective survey of the indications and morbidity of circumcision in children. European Urology 1985 11(3):184-7.

15. Williams N, Kapila L. Complications of circumcision. Br J Surg 1993; 80:1231-36.

16. Killick CJ, Barton CJ, Aslam S, Standen GR. Prenatal diagnosis in factor XIII-A deficiency. Arch Dis Child Fetal Neonatal Ed 1999;80:F238-F239.

17. Hiss J, Horowitz A, Kahana T. Fatal haemorrhage following male ritual circumcision. J Clin Forensic Med 2000;7:32-4.

18. Corbett HJ, Humphrey GME. Early complications of circumcisions performed in the community. Br J Gen Pract 2003;53(496):887-8.

19. Newell TEC. Judgement of inquiry into the death of McWillis, Ryleigh Roman Bryan. Burnaby, B.C.: British Columbia Coroner's Service, Monday, 19 January 2004.

20. Brimhall JB. Amputation of the penis following a unique method of preventing hemorrhage after circumcision. St Paul Med J 1902; 4: 490

21. Lerner BL. Amputation of the penis as a complication of circumcision. Med Rec Ann 1952;46:229-31.

22. Levitt SB, Smith RB, Ship AG. Iatrogenic microphallus secondary to circumcision. Urology 1976; 8: 472-4.

23. Izzidien AY. Successful replantation of a traumatically amputated penis in a neonate. Journal of Pediatric Surgery April 1981,16(2):202-203.

24. Hanash KA. Plastic reconstruction of partially amputated penis at circumcision. Urology 1981; 18(3): 291-3.

25. Azmy A, Boddy SA, Ransley PG. Successful reconstruction following circumcision with diathermy. Br J Urol 1985; 57: 587-8.

26. Yilmaz AF, Sarikaya S, Yildiz S, et al. Rare complication of circumcision: penile amputation and reattachment. European Urology (Basel) 1993; 23(3): 423-424.

27. Audry G, Buis J, Vazquez MP, Gruner M. Amputation of penis after circumcision--penoplasty using expandable prosthesis. Eur J Pediatr Surg 1994; 4: 44-5.

28. Hanukoglu A, Danielli L, Katzir Z, Gorenstein A, Fried D. Serious complications of routine ritual circumcision in a neonate: hydro ureteronephrosis, amputation of glans penis, and hyponatraemia. Eur J Pediatr 1995; 154: 314-5.

29. Gluckman GR et al. Newborn Penile Glans Amputation During Circumcision and Successful Reattachment. Journal of Urology (Baltimore), vol. 153 no. 3 Part 1 March 1995 pp. 778-779.

30. Strimling BS. Partial amputation of glans penis during Mogen clamp circumcision. Pediatrics 1996; 97: 906-7.

31. Neulander E, Walfisch S. Kaneti J. Amputation of distal penile glans during neonatal ritual circumcision -- a rare complication. Br J Urol 1996; 77: 924-5.

32. Sherman J, Borer JG, Horowitz M, Glassberg KI. Circumcision: successful glanular reconstruction and survival following amputation. J Urol 1996; 156: 842.

33. Van Howe RS. Re: circumcision: successful glanular reconstruction and survival following traumatic amputation (Letter). J Urol. 1997;158:550.

34. Coskunfirat OK, Sayiklkan S, Velidedeoglu H.. Glans and penile skin amputation as a complication of circumcision (letter). Ann Plast Surg 1999;43(4):457.

35. Siegel-Itzkovich J. Baby's penis reattached after botched circumcision. BMJ 2000;321:529.

36. Park JK, Min JK, Kim HJ. Reimplantation of an amputated penis in prepubertal boys. J Urol 2001;165:586-7.

37. Holt LE. Tuberculosis acquired through ritual circumcision. JAMA 1913;LXI(2):99-102.

38. Reuben MS. Tuberculosis from ritual circumcision. Proceedings of the New York Academy of Medicine 1916; (December 15): 333-334.

39. Rosenstein JL. Wound diphtheria in the newborn infant following circumcision. J Pediatr 1941;18:657-8.

40. Gairdner D. The fate of the foreskin. A study of circumcision. BMJ 1949; 2: 1433-37.

41. Scurlock JM, Pemberton PJ. Neonatal meningitis and circumcision. Med J Aust 1977;1:332-334.

42. Cleary TG, Kohl S. Overwhelming infection with group B beta-hemolytic streptococcus associated with circumcision. Pediatrics, Vol 64, no 3, (September 1979), pp. 301-303.

43. Hiss J., Horowitz A., Kahana T. Fatal haemorrhage following male ritual circumcision. J Clin Forensic Med 2000;7:32-4.

44. Newell TEC. Judgement of inquiry into the death of McWillis, Ryleigh Roman Bryan. Burnaby, B.C.: British Columbia Coroner's Service, Monday, 19 January 2004.

45. Paediatric Death Review Committee: Office of the Chief Coroner of Ontario. Circumcision: a minor procedure? Paediatr Child Health 2007;12(4):311-2

47. Bollinger, D. and Van Howe, R. , "Alexithymia and Circumcision Trauma: A Preliminary Investigation," International Journal of Men's Health (2011); 184-195.

48.Glover E. The ‘screening’ function of traumatic memories. Int J Psychoanal 1929; 10:90-93.

49. Cansever G. Psychological effects of circumcision. Br J Med Psychol 1965; 38: 321-31.

50. Flaherty, JA. Circumcision and Schizophrenia. J Clin Psychiatry 1980; 41: 96-98.

51. Kennedy H. Trauma in childhood: signs and sequelae as seen in the analysis of an adolescent. The Psychoanalytic Study of the Child 1986; 41:209-219.

52. Gunnar MR, Porter FL, Wolf CM, Rigatuso J, Larson MC. Neonatal stress reactivity: predictions to later emotional temperment. Child Dev 1995; 66: 1-13.

53. Davis M, Emory E. Sex differences in neonatal stress reactivity. Child Dev 1995; 66: 14-27.

54. Goldman R. The psychological impact of circumcision. BJU International 1999; 83, Suppl. 1:93-102.

55. Rhinehart J. Neonatal circumcision reconsidered. Transactional Analysis Journal 1999; 29(3):215-221.

56. Boyle GJ, Goldman R, Svoboda JS, Fernandez E. Male circumcision: pain, trauma and psychosexual sequelae. .J Health Psychol 2002;7(3):329-43.

57. Gerharz EW, Ransley PG, Woodhouse CRJ. Urinary retention, erectile dysfunction and penile anaesthesia after circumcision: a mixed dissociative (conversion) disorder. Int Urol Nephrol 2005;37(3):525-

58.Frisch, M., Lindholm, M., and Grønbæk, M., "Male Circumcision and Sexual Function in Men and Women: A Survey-based, Cross-sectional Study in Denmark," International Journal of Epidemiology (2011); 1-15.

59. "Circumcision Policy Statement." Circumcision Policy Statement. N.p., n.d. Web. 26 Aug. 2012. <http://pediatrics.aappublications.org/content/103/3/686.full>.

60. Belluck, Pam. "Group Backs Ritual 'Nick' as Female Circumcision Option." The New York Times. The New York Times, 07 May 2010. Web. 23 Aug. 2012.

Just published a few days ago in The Journal of Sexual Medicine: "We assessed the association between circumcision status and self-reported history of STI/HIV infection using logistic regressions to explore whether circumcision conferred protective benefit...

Compared with uncircumcised men, circumcised men have accumulated larger numbers of STI in their lifetime, have higher rates of previous diagnosis of warts, and were more likely to have HIV infection. Results indicate that being circumcised predicted the likelihood of HIV infection."

ABSTRACT

Introduction.  Circumcision among adult men has been widely promoted as a strategy to reduce human immunodeficiency virus (HIV) transmission risk. However, much of the available data derive from studies conducted in Africa, and there is as yet little research in the Caribbean region where sexual transmission is also a primary contributor to rapidly escalating HIV incidence.

Aim.  In an effort to fill the void of data from the Caribbean, the objective of this article is to compare history of sexually transmitted infections (STI) and HIV diagnosis in relation to circumcision status in a clinic-based sample of men in Puerto Rico.

Methods.  Data derive from an ongoing epidemiological study being conducted in a large STI/HIV prevention and treatment center in San Juan in which 660 men were randomly selected from the clinic's waiting room.

Main Outcome Measures.  We assessed the association between circumcision status and self-reported history of STI/HIV infection using logistic regressions to explore whether circumcision conferred protective benefit.

Results.  Almost a third (32.4%) of the men were circumcised (CM). Compared with uncircumcised (UC) men, CM have accumulated larger numbers of STI in their lifetime (CM = 73.4% vs. UC = 65.7%; P = 0.048), have higher rates of previous diagnosis of warts (CM = 18.8% vs. UC = 12.2%; P = 0.024), and were more likely to have HIV infection (CM = 43.0% vs. UC = 33.9%; P = 0.023). Results indicate that being CM predicted the likelihood of HIV infection (P value = 0.027).

Conclusions.  These analyses represent the first assessment of the association between circumcision and STI/HIV among men in the Caribbean. While preliminary, the data indicate that in and of itself, circumcision did not confer significant protective benefit against STI/HIV infection. Findings suggest the need to apply caution in the use of circumcision as an HIV prevention strategy, particularly in settings where more effective combinations of interventions have yet to be fully implemented.

Rodriguez-Diaz CE, Clatts MC, Jovet-Toledo GG, Vargas-Molina RL, Goldsamt LA, and García H. More than foreskin: Circumcision status, history of HIV/STI, and sexual risk in a clinic-based sample of men in Puerto Rico. J Sex Med

***WARNING: this article contains very graphic material that is not intended to be viewed by children. Some adults may be offended by it, as well. Viewer discretion is advised.***

It is often said that a "Plastibell" circumcision is painless and doesn't involve any cutting or blood. Many people say that it is a more "gentle" circumcision without any risks. All of these statements are false. No circumcision is painless. The foreskin contains thousands of concentrated, specialized nerve endings. It is the most sensitive part of the penis. Any cutting on this part of the body is extremely painful, even with anesthetic (which will never provide 100% pain relief).

All circumcisions involve cutting, tearing and blood (even Plastibell methods). From birth, the foreskin is fused to the head of the penis (like a fingernail is fused to a finger). Before any circumcision begins, the foreskin must be ripped away from the glans. With a Plastibell circumcision, typically the foreskin is slit down the top to allow the insertion of the Plastibell. When in place, a string is tightly tied to necrotize the foreskin. After everything is secured, the excess skin is removed with scalpel or scissors.

A video of a Plastibell infant circumcision can be seen below:

The Plastibell procedure also has many dangers. It is not "safer" or "without risk". In fact, there are studies surrounding the complications of this method. Below are some photos involving just a few complications from Plastibell circumcisions:

(Above) Plastibell ring which has migrated proximally onto the penile shaft 8 days after circumcision. Patient experienced extensive skin loss over penile shaft. Read more about this story here.

We present the case of a 4-year-old boy who, shortly after a Plastibell circumcision, with the ring still in situ, experienced trauma to his glans, resulting in complete amputation. The second photo shows removal of dressing 7 days post injury. Read more about this story here.

Retained Plastibell ring from the University of Florida Pediatrics

(Above) A term, 10-day-old infant was brought to the hospital for evaluation of tenderness and swelling involving his penis, scrotum, and lower abdomen 2 days after he had undergone Plastibell circumcision. He was diagnosed with Necrotizing Fasciitis. Read more about this story here.

A 2.6-kg male infant was born by normal vaginal delivery after 39 weeks gestation. He was circumcised without incident by the Plastibell technique at age 3 days. Two days later, his mother noticed slight penile swelling and a small amount of blood and pus on the diapers. Later in the day, the penis and scrotum turned black-purple in color. The Plastibell was removed at another hospital and he was transferred to our institution. Read more about this story here.

MEDICAL JOURNAL: Twenty-three injuries resulting from circumcision with the Plastibell device all occurred from prolonged retention of the ring. In each case, the ring was retained and had migrated proximally. There was extensive skin loss in 17 (74%) babies. Urethrocutaneous fistulae were the result in nine (39%) of these cases, while partial necrosis of the glans penis occurred in four (17%).

http://www.ncbi.nlm.nih.gov/pubmed/19570722

Your Uncircumcised Son:
Expert Medical Advice for Parents
by: Paul M. Fleiss

Increasing numbers of American parents today are protecting their sons from routine circumcision at birth, but as their boys grow up, they often find themselves at odds with doctors who cling to old-fashioned opinions and hospital routines.

I often receive calls from distraught parents who say that a doctor insists that their little boy needs to be circumcised because there is something wrong. When they bring their son into my office, I almost always find that there's nothing wrong with the child's penis. Occasionally there's a slight infection, but that can be quickly cleared with an antibiotic cream. In all my years of practice, I've never had a patient who had to be circumcised for medical reasons.

  When a doctor advises that your son be circumcised, it's usually because he or she is unfamiliar with the intact penis, misinformed about the true indications for surgical amputation of the foreskin, unaware of the functions of the foreskin, and uncomfortable with the movement away from routine circumcision.

Doctors can be psychologically challenged by the sight of an intact boys. They may see problems with the penis that do not really exist. They may try to convince you that the natural penis is somehow difficult to care for. They may cite "studies" and "statistics" that appear to support circumcision.

Probably the only problem you will encounter with a foreskin is that someone will think that he has a problem. The foreskin is a perfectly normal part of the human body, and it has very definite purposes, as do all body parts, even if we do not readily recognize them. There's no need to worry about your son's intact penis.

WHAT TO SAY WHEN THE DOCTOR SAYS TO CUT

Below is a list of some of the things that doctors have said to parents in an attempt to convince them to agree to a circumcision. After each incorrect statement, I've given you the medical facts to help you understand what your doctor may not know about the intact penis and its care, and what you need to know to protect your child from unnecessary penile surgery. If you ever find yourself in a situation where a doctor suggests that your child should be circumcised, the best thing that you can say is simply: "Leave it alone."

Your son's foreskin should be cut off in order to facilitate hygiene.
My experience as a pediatrician has convinced me that circumcision makes the penis dirtier, a fact that was confirmed by a study recently published in the British Journal of Urology.1 For at least a week after circumcision, the baby is left with a large open wound that is in almost constant contact with urine and feces--hardly a hygienic advantage. Additionally throughout life the circumcised penis is open and exposed to dirt and contaminants of all kinds. The wrinkles and folds that often form around the circumcision scar frequently harbor dirt and germs.

Thanks to the foreskin, the intact penis is protected from dirt and contamination. While this important protection is extremely useful while the baby is in diapers, the foreskin provides protection to the glans and urinary opening for a lifetime. At all ages the foreskin keeps the glans safe, soft, and clean.

Throughout childhood, there is no need to wash underneath the foreskin. Mothers used to be advised to retract the foreskin and wash beneath it every day. This was very bad advice indeed. When the foreskin becomes fully retractable, usually by the end of puberty, your son can retract it and rinse his glans with warm water while he is in the shower.

Your son's foreskin is too tight, it doesn't retract. He needs to be circumcised.
The tightness of the foreskin is a safety mechanism that protects the glans and urethra from direct exposure to contaminants and germs. The tight foreskin also keeps the boy's glans warm, clean, and moist, and when he is an adult, it will give him pleasure. As long as your son can urinate, he is perfectly normal. There is no age by which a foreskin must be retractable. Don't let your doctor or anyone try to retract your son's foreskin. Optimal hygiene demands that the foreskin of infants and children be left alone. Premature retraction rips the foreskin of the penis open and causes your child extreme pain. There is no legitimate medical justification for retraction. The child's discomfort is proof of that.

Do NOT let your doctor or anyone else try to retract your child's foreskin.

Your son's foreskin is "adhered" to the glans. It must be amputated.
The attachment of the foreskin and glans is nature's way of protecting the undeveloped glans from premature exposure. Detachment is a normal physiological process that can take almost two decades to complete. By the end of puberty, the foreskin will have detached from the glans because hormones that are produced in great quantities at puberty help with the process. There is no age by which a child's foreskin must be fully separated from the glans.

Some misguided doctors might suggest that the "adhesions" between the foreskin and the glans should be broken so that your son can retract his foreskin. This procedure is called synechotomy. To perform it a doctor pushes a blunt metal probe under the foreskin and forcibly rips it from the glans. It's as painful and traumatic as having metal probe stuck under your fingernail to pull it off. It will also cause bleeding and may result in infection and scarring of the inner lining of the foreskin and the glans. The wounds that are created by this forced separation can fuse together, causing true adhesions. There is no medical justification for this procedure because the foreskin is not supposed to separate from the glans in childhood. If any doctor suggests this procedure for your son, firmly refuse, stating, "Leave it alone!"

Your son's foreskin is getting tighter. It no longer retracts. Something is wrong. He will have to be circumcised.
Sometimes, in childhood, a previously retractable foreskin will become resistant to retraction for reasons that are unrelated to impending puberty. In these cases, the opening of the foreskin may look chapped and sting when your son urinates. This is not an indication for surgery any more than chapped lips. This is just the foreskin doing its job. If the foreskin were not there, the glans and urinary opening would become chapped instead. Chapping is most often caused by overly chlorinated swimming pools, harsh soap, bubble baths, or a diet that is too high in sugar, all of which destroy the natural balance of skin bacteria and should be avoided if chapping occurs. The foreskin becomes resistant to retraction until a natural and healthy bacterial balance is reestablished.

You can aid healing by having your son apply a little barrier cream or some ointment to the opening of the foreskin. Acidophilus culture (which can be purchased from a health food store) can be taken internally and also applied to the foreskin several times a day to assist healing, and should be given any time a child is taking antibiotics.

Your son's foreskin is red, inflamed, itching, and uncomfortable, It has an infection and needs to be cut off.
Sometimes the tip of the foreskin does become reddened. During the diaper-wearing years, this is usually ammoniacal dermatitis, commonly known as diaper rash. When normal skin bacteria and feces react with urine, they produce ammonia, which burns the skin and causes inflammation and discomfort. If the foreskin were amputated, the inflammation would be on the glans itself and could enter the urethra. When the foreskin becomes reddened, it is doing its job of protecting the glans and urinary meatus.

Circumcision will have no effect on diaper rash. Change your baby's diaper more frequently and use a barrier cream until the rash clears. Harsh bath soaps can also cause inflammation of the foreskin. Use only the gentlest and purest of soap on your child's tender skin. Resist the temptation to give your child bubble baths, because these are harmful to the skin. Never use soap to wash the inner foreskin because it is mucous membrane just like the inner lining of the eyelid.

Foreskin infections are extremely rare, but if they occur, one of the many simple treatment options is antibiotic ointment along with bacterial replacement therapy. (Acidophilus culture). We don't amputate body parts because of an infection. Most infections of the foreskin are actually caused by washing the foreskin with soap. Leave the foreskin alone, remembering that it doesn't need any special washing, and infections will be unlikely to occur.

Your son is always pulling on his foreskin. He should be circumcised.
I can assure you that, whether circumcised or not, all little boys touch and pull on their penis. It is perfectly normal. Intact boys pull on the foreskin because it is there to pull on. Circumcised boys pull on the glans because it is that is all they have to pull on. Little boys sometimes will adjust the position of their penis in their underpants. They will sometimes explore the interior of the foreskin with their fingers -- a perfectly normal curiosity and nothing to worry about. It is important for parents to cultivate an enlightened and tender congeniality about such matters, otherwise they risk transferring unhealthy attitudes to their children.

Sometimes a boy will pull on his foreskin because it itches. All parts of the body itch occasionally. Even a circumcised boy has to scratch his penis. Just as you don't worry every time your child scratches his knee, so you should not worry when he scratches his penis. If the itch is caused by dry skin, then have your son avoid using soap on his penis. Treat the foreskin as you would any other part of the body.

If the real fear is masturbation, calmly remind yourself of the simple, natural fact that all children will explore their bodies, including their genitals. Touching the genitals gives children a pleasant feeling and relaxes them. Classic anatomical studies demonstrate that the foreskin is the most pleasurably sensitive part of the body. You can congratulate yourself for having protected your child from a surgical amputation that would have permanently denied him normal sensations.

Your son's foreskin is too long, it should be cut off.
There is tremendous variation in foreskin length. In some boys, the foreskin represents over half the length of the penis. In others it barely reaches the end of the glans. All variations are normal. The foreskin is never "just extra skin" or "redundant." It is all there for a reason.

Your child should be circumcised now because it will hurt more if it has to be done later, or worse when he is an adult.
This excuse is tragically wrong and has resulted in a very serious crisis in American medical practice. It is based on the false notion that infants and young children do not feel pain. Babies can see, hear, taste, smell, and feel. In fact babies feel pain more acutely than adults, and the younger the baby, the more acutely the pain is felt. If an adult needed to be circumcised, he would be given anesthesia and postoperative pain relief. Doctors almost never give babies either of these. The only reason doctors get away with circumcising babies without anesthesia is because the baby is defenseless and cannot protect himself. His screams of pain, terror, and agony are ignored. In any event, this all too common excuse is merely a scare tactic, one with tragic consequences for any baby forced to endure a surgical amputation without the benefit of anesthesia.

Your son is having anaesthesia for another operation, we'll just go ahead and circumcise him.
Most parents are never told that their son is in danger of being circumcised during a tonsillectomy or surgery for an undescended testicle. It would never occur to them. If your child is going into hospital for any reason, be certain that you tell the physician, surgeon, and nurse that under no circumstances is your child to be circumcised. Write "No Circumcision" on the consent form, too. Then if your child is circumcised against your wishes, remember that you have legal recourse.

Your son has cysts under his foreskin. He needs to be circumcised.
During the period when the foreskin is undergoing the slow process of detaching itself from the glans, sloughed skin cells (smegma) may collect into small pockets of white "pearls." These are not cysts. Some doctors mistakenly think that the smegma under the foreskin is an infection, even though it is white rather than red, is cold to the touch, and is painless. As the foreskin proceeds with detachment, the body will do its job, and those pearls will pass out of the foreskin all by themselves. These collected pockets of cells are nothing to worry about. They are simply an indication that the natural process of detachment is occurring.

In all my years of practice, I have never had a patient who had to be circumcised for medical reasons.

Your son has a urinary tract infection (UTI) and needs to be circumcised to prevent it from happening again.
The belief that the foreskin is slightly increases the chances of a boy having UTI is highly controversial and, more importantly, unproven. Members of the medical profession in Europe do not accept it. Medical research proves that UTIs are most often caused by internal congenital deformities of the urinary tract.2,3,4 The foreskin has nothing to do with this. Even if it could be proven that circumcision slightly reduces the risk of UTI, it is an absurd proposal because UTIs in boys are extremely rare and are easily treated with antibiotics. Breastfeeding, too, helps prevent UTIs. Child-friendly doctors advocate breastfeeding not penile surgery.

Your son sprays when he urinates. Circumcision will correct this.
In almost every intact boy, the urine stream flows out of the urinary opening in the glans and through the foreskin in a neat stream. During the process of penile growth and development, some boys go through a period where the urine stream is diffused. Undoubtedly, many of these boys take great delight in this phase, while mothers, understandably find it less amusing. If your boy has entered a spraying phase, simply instruct him to retract his foreskin enough to expose the meatus when he urinates. He will soon outgrow this phase.

Your son's foreskin balloons when he urinates. He needs to be circumcised or else he will suffer kidney damage.
Ballooning of the foreskin during urination is a normal and temporary condition in some boys. It results in no discomfort and is usually a source of great delight for little boys. Ballooning comes as a surprise only to those adults who have no experience with this phase of penile development. It certainly does not cause kidney damage; it has nothing to do with the kidneys. Ballooning disappears as the foreskin and glans separate and the opening of the foreskin increases in diameter. It requires no treatment.

Your son caught his foreskin in the zipper of his trousers; we will have to cut it off.
There have been rare cases where a boy has accidentally caught part of the skin of his penis in the zipper of his trousers. This is painful and can cause a lot of bleeding. Cutting off the foreskin, however, is illogical in this situation. By cutting across the bottom of the zipper with scissors, the zipper can easily be opened to release the penile tissue. Any laceration in the skin can then be closed with either sutures or surgical tape, depending on the situation. The proper standard of care in this situation is to minimize and repair the injury, not make to worse by cutting off the foreskin and creating a larger and more painful surgical wound.

Your son has phimosis. He needs to be circumcised to correct this problem.
Phimosis is often used as a diagnosis when a doctor does not understand that the child's foreskin is supposed to be long, narrow, attached to the glans, and resistant to retraction. Some doctors use prescribing steroid creams for phimosis, but this is unnecessary in children, since the foreskin does not need to be retracted in young boys. The hormones of puberty will do the same thing at the appropriate time that a steroid cream is doing prematurely. In adults who have a foreskin that is securely attached to the glans or a foreskin with such a narrow opening that the glans cannot pass easily pass through it, steroid creams are a conservative therapy. This is if the adult wants a foreskin that fully retracts. Many males don't, preferring a foreskin that remains securely over the glans. It is purely a matter of personal choice, one that only each male can decide for himself.

Your son has paraphimosis and must be circumcised to prevent it from happening again.
Paraphimosis is a rare dislocation of the foreskin. It is caused by the foreskin being prematurely retracted and becoming stuck behind the glans. The dislocation can most often be corrected by applying firm but gentle pressure on the glans with the thumbs as though you were pushing a cork into a bottle. To reduce the swelling, an injection of hyaluronidase may be effective. Doctors in Britain have also reported good results from packing the penis in granulated sugar.5 Ice packs work well, too.

Your son has BXO and will have to be circumcised.
Some doctors equate phimosis with an extremely rare skin disorder called balanitis xerotica obliterans (BXO) which is also called lichen scherosus et atrophicus (LSA). BXO can appear anywhere on the body, but if this disorder affects the foreskin, it may turn the opening hard, white, sclerotic, and make retraction almost impossible. BXO is usually painless and progresses very slowly. Many times it goes away by itself. To an experienced dermatologist, there is no mistaking BXO, but a diagnosis must be confirmed by an biopsy. The good news is that BXO can almost always be successfully cured with steroid creams, carbon dioxide laser treatment, or even antibiotics. Circumcision should be considered only after every other treatment option has failed. Just as we do not amputate the labia of females with BXO or the glans of circumcised boys with BXO, it is logical that we should not amputate the foreskin of intact boys with BXO.

Your son needs to be circumcised or else he won't enjoy oral sex as an adult.
I'm afraid that doctors really have said such inappropriate things to parents. Such a statement is evidence of ignorance of the normal functions of the foreskin ad sensations of the intact penis. Classic anatomical investigations have proven that the foreskin is the most richly innervated part of the penis. It has specialized nerve receptors that are directly connected to the pleasure centers of the brain. Your intact son is far better equipped to enjoy all aspects of lovemaking than his circumcised peers.

The myth that American women prefer the circumcised penis, in my opinion, demeaning to women. It may be true that American women of a certain generation and social background were more likely to be familiar with the circumcised penis than the intact penis, but this was the result of the mass circumcision campaigns of the 1950s not personal preference. I suspect that what women prefer in men is more related to the personal qualities of consideration, gentleness, sensitivity, warmth, and supportiveness. It is very unlikely that circumcision increases a male's capacity to develop these qualities.

Your son needs to be circumcised so that he looks like his father.
A child is a mixture of both his mother's and his father's genetic heritage. He doesn't need to look like his father, nor will he ever look like his father in every way. Each child is a unique gift, and that uniqueness should be cherished. The idea that a boy will be disturbed if his penis does not look like his father's was invented to manipulate people into letting doctors circumcise their children. It has no basis in medical fact.

There are no published reports of an intact boy being disturbed because part of his penis was not cut off when he realized that part of his father's penis had been cut off. When intact boys with circumcised fathers express their feelings on the matter, they consistently report their immense relief and gratitude that they were spared penile surgery. They express sadness, as well, for the suffering their dads experienced as infants.6

Occasionally, a circumcised father will state that he wants his child circumcised because he think that it will create a bond between him and his son. It is a wonderful thing for a father to want to establish such a bond, but circumcision cannot accomplish this worthy goal. If a father wants to establish a lasting and meaningful bond with his son, the very best way, and perhaps the only way, he can achieve this is by spending quality time with him and by showing him much affection.

Sadly, some fathers who have been circumcised have an unhealthy attitude may look for any excuse to schedule the child for circumcision. Putting a child in a position where he fears that part of his penis is going to be cut off is abusive. When fathers demand that their son be circumcised, I suspect that they are desperately trying to justify their own circumcised condition. The emotions that some fathers feel when they are forced to confront the fact that part of their penis is missing can be so disturbing that they will do anything to block them out.

A father who forcibly circumcises has son will not win his son's gratitude, affection, trust, or love. I am aware of instances where such events have permanently destroyed the father-son bond and changed a son's love for this father into rage and bitter resentment. In situations where the father suffers from an unhealthy attitude about his son's normal penis, I think it is best for everyone concerned--especially the son--for the father to receive compassionate psychological counseling to help him overcome his problem. All children deserve the safest, most nurturing, and most loving home possible.

When physicians realize the important functions of the foreskin, they'll realize that just about every problem with it can and should be solved without cutting it off. Cutting off part of the body--especially part of the penis--is an extreme measure that should be reserved for the most extreme of circumstances. The only legitimate indications for cutting off any part of the body, including the foreskin, are life-threatening disease, life-threatening deformity, or irreparable damage. These situations are extremely rare.

The best advice for care of the intact penis is simply to leave it alone. The intact penis needs no special care. Let your boy take care of it himself, and when he is old enough, he will enjoy taking care of his own body. After all, it is his business. Just relax and avoid worrying about your son's intact penis. Remind yourself that the foreskin is a natural and healthy part of the body. If European boys grow up healthy and unconcerned about foreskins, so can your son.



NOTES
1. R.S. Van Howe, "Variability in Penile Appearance and Penile Findings: A Prospective Study," British Journal of Urology 80, no. 5 (November 1997): 776-782.

2. J. Winberg, I. Bollgren, L. Gothefors, M. Herthelius, and K. Tullus, "The Prepuce: A Mistake of Nature?" The Lancet 8638, no. 1 (March 1989) 598-599.

3. S. M. Downs, "Technical Report: Urinary Tract Infections in Febrile Infants and Young Children." The Urinary Tract Subcommittee of the American Academy of Pediatrics Committee on Quality Improvement, Pediatrics 103, no 4 (April 1999): e54.

4. M. A. Gill and G. E. Schutze, "Citrobacter Urinary Tract Infections in Children." Pediatric Infectious Disease Journal 18, no. 10 (October 1999): 889-892.

5. R. Kerwat. A. Shandall, and B. Stepheson, "Reduction of Paraphimosis with Granulated Sugar", British Journal of Urology 82, no. 5 (November 1998): 755.

6. Rosemary Romberg, Circumcision: The Painful Dilemma (South Hadley, Mass.: Bergen & Garvey, 1985).

FOR MORE INFORMATION

Organizations
If your physician or health care provided ever recommends that your child be circumcised, get another opinion from a physician. We have a list of foreskin-friendly doctors here.

Doctors are encouraged to contact and join:
Doctors Opposing Circumcision (DOC) 2442 NW Market Street, #42, Seattle, WA 98107. 360-385-1882. Fax 360-385-1948. faculty.washington.edu/gcd/DOC

Another resource especially for nurses:
Nurses for the Rights of the Child, 369 Montezuma #354, Santa Fe, NM 87501. 505-989-7377. www.cirp.org/nrc

For information about alternative bris for Jewish parents:
Circumcision Resource Center. Ronald Goldman, PhD, PO Box 232, Boston, MA 02133 617-523-0088. www.circumcision.org

One of the best sources of information on the Internet:
The Circumcision Information and Resource Pages. www.cirp.org

Books
Denniston, G. C., F.M. Hodges, and M.F. Milos. Eds. Male and Female Circumcision: Medical, Ethical, and Legal Issues in Pediatric Practice. Kluwer Academic/Plenum Press, 1999.

Goldman, Ronald. Circumcision: The Hidden Trauma Vanguard, 1996.

Illingworth, Ronald S. The Normal Child: Some Problems of the Early Years and Their Treatment. Tenth Edition. Churchill Livingstone, 1991.

Ritter, Thomas, and George C. Denniston. Say No to Circumcision! Second Edition, Hourglass, 1996.

Books of special interest to Jewish parents
Goldman, Ronald. Questioning Circumcision: A Jewish Perspective, Vanguard, 1997.

Hoffman. Lawrence A. Covenant of Blood: Circumcision and Gender in Rabbinic Judaism. University of Chicago Press, 1996.

Weiner, Kayla. Jewish Women Speak Out: Expanding the Boundaries of Psychology. Canopy Press, 1995.

Important medical journal articles
DeVries, C. R., A. K. Miller, and M. G. Packer. "Reduction of Paraphimosis with Hyaluronidase." Urology 48 (1996): 464-465.

Fleiss, P. M., F. M. Hodges, and R. S. Van Howe. "Immunological Functions of the Human Prepuce." Sexually Transmitted Infections 74 (1998): 364-367.

Jorgensen, E. T. and A. Svensson. "Problems with the Penis and Prepuce in Children: Lichen Sclerosus Should Be Treated with Corticosteroids to Reduce Need for Surgery," British Medical Journal 313 (September 14, 1996): 692.

Nolan, J. F. T., J. Stillwell, and J. P. Sands, Jr. "Acute Management of the Zipper-Entrapped Penis." Journal of Emergency Medicine 8 (1990): 305-307.

Shaw, Angus. "Africa to Address AIDS at Conference." Science (September 10, 1999).

Van Howe, R. S. "Circumcision and HIV Infection: Review of the Literature and Meta-analysis." International Journal of STD & AIDS 10 (1999): 8-16.

Van Howe, R. S. "Does Circumcision Influence Sexually Transmitted Diseases? A Literature Review." British Journal of Urology International 83, Supplement 1 (1999): 52-62.

Paul M. Fleiss, MD, MPH, is assistant clinical professor of pediatrics at the University of Southern California Medical Center and is in private practice in Los Angeles, California. He is the author of numerous scientific articles published in leading national and international journals.

  [This article was previously published in Mothering Magazine, Number 103, November/December 2000: Pages 40-47.]