New Study: Australia Rejects Circumcision as a Preventative for HIV

10/13/2011

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"Circumcision of infants or other minors has no place among HIV control measures in the Australian and New Zealand context; proposals such as these should be rejected."

Below is a recent study, published on October 4, 2011, by the Australian and New Zealand Journal of Public Health. You can find the original paper here.

Objective: To conduct a critical review of recent proposals that widespread circumcision of male infants be introduced in Australia as a means of combating heterosexually transmitted HIV infection.

Approach: These arguments are evaluated in terms of their logic, coherence and fidelity to the principles of evidence-based medicine; the extent to which they take account of the evidence for circumcision having a protective effect against HIV and the practicality of circumcision as an HIV control strategy; the extent of its applicability to the specifics of Australia's HIV epidemic; the benefits, harms and risks of circumcision; and the associated human rights, bioethical and legal issues.

Conclusion: Our conclusion is that such proposals ignore doubts about the robustness of the evidence from the African random-controlled trials as to the protective effect of circumcision and the practical value of circumcision as a means of HIV control; misrepresent the nature of Australia's HIV epidemic and exaggerate the relevance of the African random-controlled trials findings to it; underestimate the risks and harm of circumcision; and ignore questions of medical ethics and human rights. The notion of circumcision as a ‘surgical vaccine’ is criticised as polemical and unscientific.

Implications: Circumcision of infants or other minors has no place among HIV control measures in the Australian and New Zealand context; proposals such as these should be rejected.

Australian medical authorities have discouraged routine circumcision of male infants since 1971, when the Australian Paediatric Association issued a short statement that the procedure should not be performed.1 Although this position was reaffirmed in subsequent years (1983, 1996, 2002)2 it was increasingly challenged in the late 1990s, when the medical literature began to feature ‘new evidence’ about the protective effect of circumcision against various diseases, particularly STIs. The debate intensified in 2006, after three randomised clinical trials in Africa that appeared to show circumcision could reduce a male's risk of acquiring HIV during unprotected sexual intercourse with an infected female partner by a significant degree, commonly reported as 60%, but estimated by the Cochrane Review as between 38% and 66%.3 Debate further intensified when the World Health Organization endorsed, and funding bodies provided the money for, large-scale circumcision programs in resource-poor African countries with high levels of heterosexually transmitted HIV.

The question Australian public health authorities then faced was whether this evidence and advice was relevant to HIV prevention in developed countries. Answering in the affirmative have been voices from Anglophone countries with past histories of routine circumcision, who have interpreted the African evidence as a vindication of past practice. Answering with a cautious negative was the Royal Australasian College of Physicians, particularly the task force it established in 2007 to review the circumcision policy statement. In Australia the pro-circumcision argument is represented by a group associated with Professor Brian Morris, a longstanding believer in circumcision as a public health measure4 and a vehement critic of the RACP's position.5 In an editorial published in the Medical Journal of Australia he and two colleagues (Professors Cooper and Wodak, both prominent figures in the HIV policy community) presented the case for “boosting infant male circumcision in the face of rising heterosexual transmission of HIV.”6 Their intervention attracted much media attention, and so much criticism that the journal published eight letters in reply.7

The replies covered many of the grounds for dissenting from the proposition that Australia's HIV problem demanded circumcision of infant males, including relevance, effectiveness, the risk of injury, harm and complications, and whether the proposal was in line with established principles of evidence-based medicine, medical ethics and human rights. Appreciating that the target of the editorial was the RACP position, the chairman of the task force that had just finalised the new policy statement defended its conclusion that circumcision should still not be recommended. A surprising omission from the replies was that none asked why the editorial had devoted so little effort to establishing the conditions that would have to be met in order to make widespread neonatal circumcision as an HIV control strategy appropriate in the Australian context. To prove the argument, it would have had to demonstrate that:

  •  the incidence of heterosexually transmitted HIV in Australia is rising to a dangerous level;
  • circumcision is the only effective way of countering this challenge;
  • widespread circumcision of male infants is necessary to prevent Australia's HIV problem growing into an epidemic on the African scale; and
  • circumcision in infancy is a safe operation with no adverse physical or psychological effects on the individual, and is acceptable within existing standards of bioethics, human rights and Australian law.
The editorial established none of these points, but confined itself to summarising the African evidence and asserting that circumcision conferred a wide range of valuable health benefits, with neither risk nor adverse effects, and that infancy was the most convenient, safe and inexpensive time to do it. The tendency to offer benefits additional to HIV protection was even more pronounced in the authors’ rejoinder to their critics.

Despite the hostile reaction to the proposal, the issue is not likely to die down in the near future, particularly as other medical authorities in Canada and the US are considering the issue and are expected to issue their own policies later this year. It is therefore appropriate to subject the circumcision prescription to a more detailed analysis. In this paper it is argued that the proposal is fatally flawed because:

  • It ignores doubts about the African evidence on which it relies and passes over numerous critiques of the clinical trials and the manner in which the WHO recommendations arising from them have been implemented.
  • It is irrelevant to the Australian situation and the specifics of Australia's HIV problem.
  • It departs from the principles of evidence-based medicine.
  • It underplays the harm and risks of circumcision.
  • It violates accepted standards of medical ethics and human rights.
  • It is marred by unscientific thinking and hyperbolic language, such as the description of circumcision as a ‘surgical vaccine’.
For these reasons, circumcision of infants as a response to Australia's HIV problem must be rejected.

The claim that circumcision prevents heterosexual HIV transmission from women to men is based on three non-double-blinded, non-placebo-controlled Random-controlled trials in Africa, in which 5,400 men were circumcised. After 20 months, 64 of the men in the circumcised experimental groups had HIV, compared to 137 in the non-circumcised control groups. Six hundred and seventy-three men were lost to follow-up, their HIV status unknown.8–10 Cooper et al. take the claimed results of these trials at face value and ignore serious doubts about their validity and applicability. As several critiques have pointed out,11–15 they fell far short of the so-called ‘gold standard’, vitiated by several forms of bias, especially selection bias, since only men interested in a free circumcision were eligible. All participants were to be circumcised, some immediately, the remainder at the conclusion of the trial. Since participants assigned to immediate circumcision were aware that they had received the treatment rather than being placed in the control group, it was impossible to blind either the researchers or the subjects. Without sham surgery there could be no placebo. The trials also suffered from expectation bias (both researcher and participant), lead-time bias, attrition bias, and premature termination.16 All these weaknesses favoured the results the investigators expected. Perhaps the most crucial flaw in these three studies is that the researchers assumed that all the men who became HIV positive during the course of the trials were infected through sexual contact. When the study results are examined closely, there is evidence that as many as half the infections could have been acquired non-sexually. In the South African trial, for example, 23 men became infected even though they had either no sexual contact or always used a condom.17 If a significant number of the men who became infected in this experiment did so through non-sexual contact, it becomes impossible to accurately estimate the protective effect of circumcision on sexual transmission of HIV.

A further problem with the random-controlled trials is that we do not know whether their results can be replicated in other high-prevalence sites outside a research setting, with their resources, expertise and monitoring, or in general, low-prevalence sites. It will be many years before we learn whether the current African circumcision programs have succeeded in significantly reducing HIV prevalence in the general population, and African population surveys suggest that the results of the clinical trials are not likely to have external validity.18 Garenne found that in eight countries (Burkina Faso, Cote d'Ivoire, Ethiopia, Ghana, Niger, Rwanda, Tanzania and Zimbabwe) there was no significant difference in HIV seroprevalence between circumcised and uncircumcised men; in two countries (Kenya and Uganda) HIV seroprevalance was higher among uncircumcised men; and in three countries (Cameroon, Lesotho and Malawi) HIV seroprevalence was significantly higher among circumcised men. In Lesotho the difference was striking: HIV seroprevalence was 22.8% among the circumcised, but only 15.2% among the uncircumcised.19 In South Africa, where a third of the population is circumcised and HIV prevalence is among the highest on record, both Garenne and Connolly et al. found no difference in HIV status between circumcised and uncircumcised samples.20 As Garenne comments, “large-scale demographic surveys, as well as routine seroprevalence surveys among pregnant women, do not show any consistent population impact of male circumcision on either HIV prevalence or HIV incidence.”21 Both the United States and Indonesia, with predominantly circumcised male populations, have a significantly higher incidence of HIV than Australia, Canada, Britain and New Zealand, where circumcision is in decline or extremely rare.22 In the United States, African-Americans exhibit both the highest rate of circumcision and the highest rate of heterosexually-transmitted HIV.23,24 Such is the faith in Western health advice, however, that in Swazliland, with an HIV prevalence of 22% among circumcised men but only 20% among the uncircumcised, the government has still announced a particularly ambitious circumcision program.25

Another objection to regarding circumcision as effective prophylaxis against HIV is that there is no convincing biological explanation of its protective effect.26 Circumcision advocates have speculated that the interior mucosa of the prepuce is thinner and more prone to tearing. While a thinner epithelial layer of genital tissue may be associated with increased internal transfer of HIV,27 the mucosa of the inner and outer prepuce have been shown to be of the same thickness in some studies28 but not in others.27 It is also suggested that HIV is more likely to be transmitted through the foreskin because it has a high concentration of Langerhans cells, believed to be the entry point for the virus. Actually, Langerhans cells are quite efficient in repelling HIV, which may explain the low transmission rate of HIV – only about one per 1,000 unprotected coital acts.29 The inner foreskin secretes langerin, which is effective in killing numerous pathogens.30 Langerhans cells may also provide protection against other STIs, which may explain why circumcised men are at greater risk of infection with some STIs, such as urethritis.31 Until we understand how circumcision works biologically, we cannot be certain whether the observed reduction in risk of infection in the random-controlled trials is the result of changed anatomy resulting from surgery, changed behaviour resulting from counseling and provision of condoms, or the various forms of bias built into the studies.

Circumcision advocates have portrayed the sub-preputial space as a harbour for sexually transmitted viruses.32 Against this, however, meta-analyses assessing susceptibility to genital infections with herpes simplex virus and human papilloma virus have not shown any meaningful association with circumcision status.33,34 Unfortunately, these portrayals have appeared so often in the medical literature that many physicians and public health officials consider them factual. There is, however, no scientific proof that the foreskin is a predisposing factor for infections of this kind.

The most serious objection to the circumcision proposal is that it is not applicable to our situation. Australia is not sub-Saharan Africa, where HIV is a generalised epidemic transmitted largely by heterosexual intercourse and non-sterile medical equipment.30,35 In Australia, HIV is a relatively low-prevalence disease, largely contained within the specific sub-cultures where it has always been found: mostly homosexual men (80%), plus a very small population of injecting drug users (4%).36 Although Daniel Halperin advised gay men who take the insertive role in anal intercourse to get circumcised,37 it is now firmly established that circumcision provides no protection to men who have sex with men (MSM),38–41 and there is evidence from Britain that circumcised gay men may be at greater risk.42 Whether that is generally the case, it is obvious that circumcision would have made no difference to the vast majority of Australian men who have become HIV positive over the past thirty years.

Cooper et al. are not so misguided as to suggest that either gay men or injecting drug users would receive any protection from circumcision, but focus on the small incidence of heterosexual transmission. This is running at such a low level, however, that the circumcision proposal is grossly out of proportion to the problem. The surveillance authority of which Cooper himself is director expresses no alarm, and in its latest report points out:

“the annual number of new HIV diagnoses has remained relatively stable at around 1000 over the past four years”;

“HIV continues to be transmitted primarily through sexual contact between men”; and

“of 1185 cases of (heterosexually acquired) HIV infection newly diagnosed in 2005–2009, 58% were in people from high prevalence countries or their partners”.43

The total number of newly diagnosed HIV infections in 2009 was 1,050, of which males made up 86.7%, down slightly from 87.4% in 2001. Over the same decade, the proportion of newly diagnosed infections among MSM has remained steady: 66.6% in 2001, 65.1% in 2009. The increase in the proportion of infections attributable to heterosexual contact from 21.8% in 2001 to 28.7% in 2009 is neither a dramatic rise nor cause for alarm, especially as nearly 60% of such infections occur in people with a partner either HIV-positive or in a high-risk category.44 The 1,185 cases of heterosexual transmission in the five years 2005–09 represent about 200 new diagnoses annually, but since the infection could have been acquired at any time this is not evidence of new cases or a rising trend. Because more than half of these are found in people from, or with a partner from, a high-prevalence country it is possible that many of these infections were not acquired in Australia.

A more relevant measure are newly acquired infections – new infections that were definitely acquired in the previous twelve months – and here there is even less cause for alarm. In 2005–09, 82% of newly acquired infections were in MSM, 3% among injecting drug users, and 10% from heterosexual contact.45 Cooper et al. refer to a rising proportion of female-to-male transmission, but the numbers are still very small (23 men newly infected in 2009), and the rate of increase is both erratic and slow.

Click to see Table 1.  Characteristics of newly-acquired HIV infection 2000–2009 
  1. Source: National Centre in HIV Epidemiology and Clinical Research. HIV, Viral Hepatitis and Sexually Transmissible Infections in Australia. Annual Surveillance Report 2010. Table 1.2.1, p. 42

Somebody desiring to impress the media could claim that the incidence of female-to-male transmission had doubled over the last decade, but the effect would not be so dramatic if it were stated that the number of cases had increased from 12 to 23. There is, moreover, no consistent pattern in the increase, and no evidence at all that uncircumcised men are over-represented in this group. Indeed, there is no Australian data suggesting that uncircumcised men are more susceptible to any STIs,46,47 including STIs that have been associated with increased susceptibility to HIV.48 What we are dealing with, if we add newly acquired infections to the 100 or so newly diagnosed infections probably acquired in Australia, is about 125 cases of heterosexually transmitted HIV per year. These are not numbers that necessitate the sort of panic response that has occurred in sub-Saharan Africa. On these figures it would be necessary to circumcise several thousand babies now to prevent one case of HIV from 2030 onwards – a proposal that would be ruled out on cost-benefit considerations alone.

The proposal is also irrelevant because it targets infants rather than adults. Infants are not at risk of infection by sexual contact and will not be at risk until they become sexually active in 16–20 years time, by which time treatment and prevention options, and the virus itself, may have altered beyond recognition. Evidence-based medicine requires that recommendations for treatment or prophylaxis follow logically and directly from the evidence. Assuming the African evidence is reliable and applicable, the logical prescription is that sexually active adult men who have regular intercourse with numerous female partners and do not always use condoms should consider circumcision for themselves. One approach might be that sexual health advice targeted at this category could include circumcision as a prophylactic option among a range of sexual health offerings, as the WHO has recommended.

This is not what Cooper et al. prescribe. Instead, they propose that parents be advised to circumcise their baby boys as a precaution against a risk they will not face until adulthood, and against a disease that is very rare among heterosexually active adult men anyway. Even if circumcised, they would still need to use a condom to be certain of avoiding infection, since the risk reduction indicated by the African data is only partial (38%–66%). We have no evidence on what the risk reduction in a low-prevalence country such as Australia might be, and with such a low level of heterosexual transmission it would be neither feasible nor ethical to mount random-controlled trials. If it is still necessary to wear a condom there seems little point in getting circumcised. As Perera et al. point out,49 moreover, the African trials involved sexually active adult men, not infants, and there is no hard evidence that neonatal circumcision has any protective effect against HIV. The prescription has little connection with the evidence on which it is presumed to depend and thus violates the principles of evidence-based medicine.

As subsequent research has confirmed,50,51 the WHO recommendations arising from the African random-controlled trials cannot be applied to developed nations, but only to regions of high HIV prevalence, in generalised epidemics with predominantly heterosexual transmission. Medical authorities responsible for formulating policy statements on neonatal circumcision have reached the same conclusion. In a strongly-worded statement against prophylactic circumcision of minors, the Royal Dutch Medical Association comments:

“That the relationship between circumcision and transmission of HIV is at the very least unclear is illustrated by the fact that the US combines a high prevalence of STDs and HIV infections with a high percentage of routine circumcisions. The Dutch situation is precisely the reverse: a low prevalence of HIV/AIDS combined with a relatively low number of circumcisions. As such, behavioural factors appear to play a far more important role than whether or not one has a foreskin.”52

The RACP reached the similar conclusion that “in low prevalence populations such as Australia and New Zealand circumcision does not provide significant protection against STIs and HIV, and is less effective than safe sex practices.”53 Cooper et al. state that “The protection conferred to heterosexual males by circumcision is similar in hyperendemic and low-prevalence settings”. This claim – crucial to their argument – is not supported by their citations, which carefully note that recommendations based on the trials pertain only to similar settings, i.e., in generalised epidemics with high HIV prevalence. That is not the kind of epidemic found in Australia.

Supporters of circumcision claim other benefits of early circumcision, but such arguments are irrelevant to the question of HIV infection itself. But even these additional claims are either contested to the point of inconclusiveness or rejected as invalid or irrelevant. Perera et al. found the benefits of neonatal or childhood circumcision to be negligible and the possibility of reduced vulnerability to HIV irrelevant to children.49 If uncircumcised boys are more subject to “adverse medical conditions”, as Cooper et al. claim, we would expect this to show up in child health reviews, but the Australian Institute of Health and Welfare found no decline in child health as the incidence of circumcision in Australia has fallen, and indeed that child health has improved over the same period.54 The RACP concluded that there was no medical justification for prophylactic circumcision of minors in Australia.53

Two glaring omissions from Cooper et al's argument are discussions of the harm and risks of circumcision and the ethics of performing amputative surgery on minors. Research on the anatomy and physiology of the foreskin is primitive, but we know that it is an anatomically integral, sexually functional and psychologically significant component of the penis, loss of which may have adverse consequences on both sexual satisfaction and psychological well-being.55 The extent to which the foreskin contributes to sexual function is in dispute,56–59 but research is so inadequate that nobody can say with confidence that circumcision ‘makes no difference’. The RACP policy statement acknowledges that the foreskin is the most sensitive part of the penis and points out that since men may resent having been circumcised as infants, it may be preferable to delay the operation until a boy reaches maturity and can give informed consent.53 It might be assumed that resentment would be less if all boys were circumcised at birth, but even when they grow up among circumcised peers many men can still feel angry and mutilated, even to the point of psychological disturbance.60 Cooper et al. cite a study claiming that neonatal circumcision is “cost effective”,61 but in fact the article was a cost analysis that did not consider cost effectiveness at all. Others have concluded that since the procedure both adds to health costs and reduces the overall health of the individual it can be justified on neither economic nor medical grounds.62 Any consideration of the costs of circumcision will be woefully inadequate if it fails to factor in the value of the foreskin to the individual and the cost of surgical complications and other adverse sequelae, both physical and psychological.

Complications from circumcision are another area where lack of both adequate data and benchmarks for acceptable risk make it impossible to be confident that the operation is ‘safe’. While all circumcisions result in the loss of the most sexually responsive portion of the penis, accurate estimates of the incidence and severity of complications are not available. In 2002 the RACP cited estimates ranging from an implausible 0.06% to an equally unlikely 55%, depending on definition, but regarded the likely incidence as falling somewhere between 2% and 10%, and warned that “serious complications, such as bleeding, septicaemia and meningitis may occasionally cause death”.63 Reported complication rates are heavily influenced by how a complication is defined and how the data is collected. One study that assessed all infants for bleeding found that circumcision resulted in excessive bleeding in 8.9% to 9.9% of cases.64 Many common complications may not be documented because they are considered par for the course, yet chart reviews have documented complication rates between 3.2%65 and 6.8%.66 Delayed complications such as meatal stenosis are often missed, yet the rate of meatal stenosis following circumcision ranges from 5% to 20%,67,68 while problems such as excessive tissue removal may not become evident until after puberty.69 Although practitioners claim that the Plastibell is a safer instrument than clamps, there are many reports of complications from this device, including two recent deaths.70–72

There is no evidence at all for the assertion that neonatal circumcision presents a lower incidence of complications than circumcision in adulthood. Indeed, one study (from a circumcising culture) found the incidence of complications in the neonatal period so high that it recommended leaving the procedure until later.73 In Australia, Leitch (1970) reported a complication rate of 15.5%,74 while a doctor who performed medical examinations of schoolboys reported that he was “appalled at the phallic mutilations exhibited by many of these children, some of whom have even been subjected to a subsequent ‘tidying up’ procedure after being badly mauled in infancy.”75 The risk of harm is likely to be greater if the operation is performed before the natural separation of foreskin from glans, and lower in adulthood, when the mature size of the penis and final foreskin length can be observed and taken into account. Males differ so much in these variables that one cut does not fit all.76 Unlike a newborn infant, moreover, an adult patient can be safely given both effective anaesthesia and post-operative pain relief. Circumcision advocates must consider adult circumcision perfectly safe, or they would be criticising the African circumcision programs for posing an unacceptable risk of harm to the men who enrol in them.

Even if the circumcision proposal were relevant to the Australian situation, to be ethically acceptable a medical intervention must pass the five tests proposed by Beauchamp and Childress:
  • • Beneficence – does the proposed procedure provide a net therapeutic benefit to the patient, considering the risk, pain, and loss of normal function?
  • • Non-maleficence – does the procedure avoid permanently diminishing the patient in any way that could be avoided?
  • • Proportionality – will the final result provide a significant net benefit to the patient in proportion to the risk undertaken and the losses sustained?
  • • Justice – will the patient be treated as fairly as we would all wish to be treated?
  • • Autonomy – lacking life-threatening urgency, will the procedure honour the patient's right to his or her own likely choice? Could it wait for the patient's assent?77
Cooper et al. ignore ethical and human rights issues, but their proposal would not be acceptable unless it was established that non-therapeutic circumcision of non-consenting minors was permissible within the above guidelines. It has been argued that in the absence of a life-threatening disorder, surrogate consent for non-therapeutic surgery of this type is ethically problematic and may not be legally valid.78–80 When there is no urgency to intervene, it is best to wait until the child can provide his own informed consent.

While we all hope that a vaccine for HIV will eventually be developed, the tendency to describe circumcision hyperbolically as a ‘surgical vaccine’ is regrettable and misleading. The comparison may appeal to scientifically naive journalists, but it has no basis in science and is irresponsible from a public health perspective, in that it may encourage high-risk behaviour.81 Circumcision provides nothing like the kind or level of protection provided by a vaccine, merely a risk reduction in one specific situation (unprotected heterosexual intercourse in a high seroprevalence setting). Circumcision advocates seem unwilling to acknowledge the difference between amputating body parts to provide limited protection against a rare disease to which the individual is unlikely to be exposed, and giving a person a needle that confers a high level of immunity to common or highly contagious diseases.

The justification for vaccinating non-consenting children is first, that it does not involve the removal of a functional body part, and secondly that the diseases to which it confers immunity are common and/or highly contagious.82 Airborne diseases, such as smallpox, diphtheria, and measles were all major killers before vaccines. Because such diseases are spread by breathing, a single child can infect a whole school. Vaccination thus protects both the individual who receives the treatment and the people with whom he comes into contact. Unlike these diseases, HIV is a low-virulence, and in Australia, a rare disease that can be avoided by appropriate risk-reducing behaviour. The colourful image of circumcision as ‘surgical vaccine’ is a contradiction in terms, on a par with ‘conjectural fact’; such rhetoric has no place in scientific debate.

Although this explanation has been questioned,83 it is generally accepted that the rapid spread of HIV in Africa was associated with a high level of sexual activity, involving numerous concurrent, but often transient sexual partnerships, widespread prostitution, both formal and informal, various forms of polygamy, and reluctance to practise safe sex or use condoms. It is also probable that a significant proportion of HIV infections are the result of non-sexual transmission, such as non-sterile medical procedures.84 These conditions were aggravated by poorly developed health services, the co-presence of numerous other epidemic diseases, such as malaria, tuberculosis and other STIs, and the refusal of local authorities to take action until the disease had spread through the population, provoked by the misconception that AIDS was a ‘gay disease’, confined to the decadent developed world.85 This crisis situation stands in dramatic contrast to that of a wealthy, developed nation such as Australia, where effective action was taken early on, based on respect for the autonomy and agency of those at greatest risk, and an emphasis on safe sex education, needle and syringe programs, and provision of condoms. This strategy has been strikingly successful: AIDS in Australia remains a relatively minor public health problem, largely confined to the sub-cultures where it has traditionally been found. There is no heterosexual epidemic that would justify a costly, authoritarian program of the type and scale that Cooper et al. propose. There is every reason to think that the strategy that Australia has pursued so successfully since the 1980s will continue to protect the vast majority of the population from this disease.86

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4 Comments
 

Why My Son is Not Circumcised

10/06/2011

19 Comments

 
Picture
by Tammy Schmit
(feel free to contact her with any questions)
Posted with Permission from Author

A good friend gave birth to her first son the day before my wedding.  It was so much fun to be a part of her pregnancy and then to watch her son grow.  I was only about 2 months pregnant when I found myself lending her a hand with a diaper change.  I noticed that her son didn’t look circumcised, so I asked her why she didn’t have that done.  She responded that while she was pregnant, a friend of hers had her son circumcised and the baby boy died of an infection that was thought to be related to the circumcision.  That was enough for her and she left her son intact. 

Well, it wasn’t enough for me because I had always just assumed I’d have a baby boy circumcised and I figured it wasn’t just as simple as blaming the death on the circumcision.  That same day, I went online to my favorite baby resource (BabyCenter.com).  I found myself on a circumcision debate board, where I lurked for several days before building up the gall to post something.  The debates were heavily dominated by anti-circumcision advocates.  It seemed that every person who planned to have their son circumcised (or already did) was getting attacked, called a bad parent and other horrible things.  Although I was taken aback by this cult-like online congregation, I was also intrigued because I had no clue there was such controversy over circumcisions.  I just thought pretty much everyone did it because it was more hygienic and looked better. 

After reading up on some of the “benefits” of circumcision, I decided to pose as a curious poster who was on the fence about circumcision.  I spent many hours over the next couple of weeks debating circumcision from the perspective of someone leaning toward having it done and constantly losing my arguments to factual data and ethical boundaries.  I was shocked by how difficult it was to find medical websites that supported circumcision.  The facts were all there, it was clearly not a necessary procedure, the health benefits were practically non-existent (medical resources only claimed "possible" benefits), but I couldn’t help but feel like I should still have it done.  I soon realized that my pro-circ stance was only still hanging around due to cultural pressures.  I put my guard down, stepped out of my comfort zone, and focused on making a logical decision. 

Leading up to the birth of our son, Jeremy and I were both in complete agreement that he would not be circumcised.  I continued to have this strange feeling in the pit of my stomach telling me that maybe I was making the wrong decision.  I knew that was my own cultural uncertainty ringing its bell and I knew now to ignore it because the facts were clear and the decision was clear.  It did NOT feel like maternal instinct urging me to take action.  Every instinct in my body told me that he was born with it for a reason and to simply leave it alone.  When Nathan was born, all hell broke loose…it was just such a difficult birth experience.  After 33 hours of unmedicated labor, Nathan was cut out of me in emergency fashion and rushed to a different hospital where he spent the next 5 days in the NICU.  Inflicting further stress on my son’s body was the furthest thing from my mind.  When I finally saw his naked little body (days after he was born), it was so perfect…every last piece of my son was beautiful.  I have NEVER doubted my decision to leave his penis intact and I know I never will.  I’m so glad that I took the time to learn about circumcision because I cannot imagine learning all of this after the fact. 

Here is a list of common reasons, in no particular order, that people present to support the decision to have their son circumcised followed by the responses I feel made the biggest impact on me.  Please realize that I am not including both sides of the debate here, just what helped change my mind.

1) I want my son to look like his daddy. 

Today, doctors perform “loose circumcisions.”  This is done because in the past, "tight circumcisions" were the norm and oftentimes too much skin was removed.  As an adult, many men suffer from tight erections that can be crooked and painful.  As a result of removing less skin, some babies don’t really look circumcised, and few will look like Daddy.  [Note: in the Jewish tradition, a Mohel performs the circumcision; traditional, tight circumcisions are apparently still the norm despite the increased risks.]   A problem that commonly arises with loose circumcisions is that unless Vaseline is applied for 10 days after circumcision, the skin tends to re-adhere in an attempt to heal back to and protect the glans (head of the penis).  The parents have to decide whether to leave it alone to separate when it is ready or to have it forcefully and painfully separated a second time.  Sometimes a second surgery isn’t even optional since the skin can grow back in an unnatural way that can cause problems (such as a skin bridge).  The reason I mention all of this is because many parents end up feeling like they shouldn’t have put their son through such a terrible procedure just to be slightly circumcised, especially if the loose circumcision subjects them to ongoing problems or lifelong deformations.  This “look like daddy” reason hits me funny because after Nathan was born, we found out that Jeremy’s dad wasn’t circumcised, either.  Jeremy never knew!  All in all, I decided that I’d rather have to one day explain to Nathan why his penis doesn’t look just like Daddy’s then have him come to me and ask why we cut part of his penis off. 

2) I don’t want my son to be teased. 

The circumcision rate has dropped drastically in the U.S.  It is practically non-existent apart from religious-reasons in the rest of the world.  Over 80% of the world’s men are intact.  Approximately 45% of America’s baby boys were left intact as of 2004 (this tends to be regional).  As of 2010, hospital circumcision rates in the U.S. have been found to be as low as 32%, so the numbers are definitely dropping quickly and I'm confident Nathan will never feel like he is the odd man out.  A big part of that is awareness, but I think a bigger part might have to do with fewer insurance companies covering this elective surgery.  I actually have to wonder if the circumcised boys will soon be the ones being chastised because they are missing out on the benefits of a full penis.  When he becomes sexually active, girls will probably have experience with both as well.  So rejection is unlikely for either group since there will be a true mix.  Even if we end up living somewhere with high circumcision rates, Nathan will unlikely be the only intact boy.  If he ever did get teased for the way his penis looks, there are all kinds of great comebacks I’m prepared to arm him with.  I want him to be happy and proud of who he is.  I’m not going to alter his body in anticipation of kids being kids.  All kids get made fun of at some point.  I’m going to focus on teaching him how to be a strong and happy individual regardless of what other people think, whether they are making fun of his hair-do, the way he walks, a goofy laugh, or his body.   I see little to no chance that my son will be anything but happy and relieved that he escaped this cultural trend.  The following link shows a world map with circumcision rates: http://www.circumstitions.com/Maps.html

3) My doctor recommends it. 

The cultural influence is so strong in this country, that even doctors will recommend circumcision, despite admitting that it is not medically necessary.  It turns out that there is no official medical organization in the world that recommends routine infant circumcision.  The potential medical benefits do not outweigh the risks and circumcision is recognized worldwide as either a religious or cosmetic surgery.  Not only do many American doctors recommend circumcision, but many American pediatricians give out bad information on the care of intact boys.  Clearly they are not up-to-date on their medical literature!  Many pediatricians will not only forcefully retract a boy’s foreskin just to take a look underneath, but they recommend that parents do the same to clean and check for problems.  This is by far the number one problem for intact boys because the foreskin should NEVER be forcefully retracted.  It will do so on its own when it is ready.  By retracting it early, you can cause great pain to your son and subject his penis to scarring, UTIs and other painful infections.  You are also committing yourself and your son to having to retract to clean sooner than necessary. 

Here is a document that can be presented to pediatricians who are not aware of the problems with forceful retractions:

http://doctorsopposingcircumcision.org/info/retraction.html

And here is a link from the same website talking about forceful retraction:

http://www.doctorsopposingcircumcision.org/info/info-forcedretraction.html

Unfortunately, doctors are also generally bad about telling parents of circumcised boys how to best care for the penis and lots of circumcised boys are suffering from re-adhesions that could have been prevented. 

It really bothers me to consider this, but circumcision is a multi-million dollar industry.  Some hospitals charge as much as $2,000 for this brief surgery.  Insurance companies are gradually refusing to cover this procedure as it is more widely accepted as cosmetic.  Either way, there is a lot of money to be made off of this quick procedure, so I could not discount the idea that doctors might have an ulterior motive. 

After my father was unable to put aside his cultural influences to focus on the actual medical information regarding circumcisions and after watching a 70-year old pediatrician scare a roomful of expecting parents into getting their kids circumcised as quickly as possible so their kids don’t get made fun of, I realized just how powerful the cultural influence is.  I want my doctor to give me up-to-date medical facts, not their biased opinions (unless I ask for them).  I need a safe place to find out the truth about circumcision and I should be able to trust any licensed physician to provide me with that information. 

4) It’s just a snip. 

Circumcisions are a delicate and dangerous procedure on a tiny, little nub of a penis.  Not only is very functional and sensitive tissue being removed, but there is always the risk of taking too much off, excessive bleeding, nerve damage to the remaining parts, and infection.  Some doctors are even still using the Mogen clamp, which has been known to accidentally remove the tip of the penis along with the foreskin.  Complication rates of circumcision are up to 35% as stated by the AAFP.  http://www.aafp.org/online/en/home/clinical/clinicalrecs/children/circumcision.html Late complication rates are at least 4.7% or more according to this study (done at one hospital): www.ncbi.nlm.nih.gov/pubmed/20155423  Adult complication rates are generally unknown as there are not many studies done, (but include hairy shaft, scars, painful erections, and more). The complication rate of meatal stenosis though is as much as 10%. http://emedicine.medscape.com/article/1016016-overview

At least parents don’t have to worry about the side affects of general anesthesia on their infant; none will be used because general anesthesia is too dangerous on a newborn.  While there are doctors who choose to use no pain relief at all, most use a topical cream called EMLA and others will use nerve blocks (nerve blocks can also be very painful and have their own set of risks, but are considered the most effective form of pain management).  Unfortunately, most doctors who do use the EMLA cream do not give the topical analgesic time to penetrate (recommended to wait at least 30 minutes after application).  Many babies actually go into shock because they aren’t able to cope with the pain.  This explains why some babies seem so calm after the procedure.  Their little bodies just shut down.  Simple monitoring of their heart rate reveals the state of shock—this scares the hell out of me. 

I also recently read that burn unit wards use foreskins for skin grafts…the skin removed during a circumcision of an infant can cover a 12”x12” area on a burn victim!  At least that skin is occasionally being used for something good.  Foreskins are also used in making certain kinds of very pricey make-up, including those promoted by Oprah Winfrey.  *Shiver*

5) The foreskin is an unnecessary part of the penis, just like the appendix. 

The foreskin is far from unnecessary or useless.  It not only protects the glans (preventing it from drying out and becoming less sensitive, preventing infection, and protecting it from the elements) and serves as a pleasurable gliding mechanism during sex and masturbation, but it is covered in sensitive nerve endings that increase pleasure.  Unfortunately, many circumcisions don’t just remove foreskin, but they also remove part or all of the frenulum (this is the area of the penis where the foreskin attaches itself to the shaft. It is considered to be one of the most sensitive parts of the penis).  Though it is not necessary to enjoy sex, the foreskin is a natural and functional part of the penis that has over 20,000 specialized nerve endings that are not found anywhere else on the body.  Fortunately, every man seems to be born with a unique love for Mr. Happy, so even if he is missing out on some added fun, they’ll still be best of friends. http://www.circumstitions.com/Works.html

6) Uncircumcised boys aren't as clean. 

Neither are uncircumcised girls.  All boys and girls need to learn how to keep their privates clean.  Intact boys should plan on spending an additional 5 seconds “playing” with their penis in the shower; however since the normal natural retraction rate doesn't occur for an average of 10 years, this isn't something the parents will need to be concerned about for most kids.  I recommend that all men and women take a shower daily and especially after breaking a sweat if they don’t want to be stinky down there.  I’ll be the first to admit that I don’t go sniffing around my hubby’s crotch at the end of the day and especially not after he’s been working out.  Of course, if I’m being honest, I usually don’t smell all that much better than him…erm…I mean…I smell like roses. :o)

I found this quote from an Islamic website interesting because it sounds just like the argument I used to use in support of circumcision: "The secretions of the labia minora accumulate in uncircumcised women and turn rancid, so they develop an unpleasant odour which may lead to infections of the vagina or urethra. I have seen many cases of sickness caused by the lack of circumcision. "

 http://www.islam-qa.com/en/ref/45528

7) I’ve heard that uncircumcised boys are at higher risk for cancer, STDs, and urinary tract infections. 

There is a lot of misleading information regarding health benefits.  While some studies show that intact men are at higher risk of contracting STDs because the virus survives longer in the moist, protected environment under the foreskin, other studies show that the dried out (or “keratinized”) glans has a tendency to crack and allow for easier transmission.  All men should be advised to practice safe sex regardless of circumcision status. 

The small increase of UTIs can be explained by the number of babies who have their foreskin forcefully retracted.  Those boys who do get UTIs should be given antibiotics just like their female counterparts.  Overall, the potential “protective” quality of being circumcised is so small that hundreds of baby boys would need to be circumcised to spare just one baby an infection that can be treated with antibiotics.  Similar infections and problems tend to occur in girls and there is always an alternative to surgery.  Here is an article that discusses how the foreskin protects against UTIs: http://www.drmomma.org/2009/12/how-foreskin-protects-against-uti.html

As for cancer, penile cancer is by far one of the rarest forms of cancer and usually only occurs in the elderly.  I certainly wasn’t about to subject Nathan to a life without part of his penis for that risk.  If he wants to lower his cancer risk when he’s an old man and not able to even get an erection anymore, I suppose he could choose to have the surgery.  Of course, I’m at such high risk for cancer that I’m being told to have a full hysterectomy and mastectomy to improve my chances of survival.  These contradictory studies can be debated all day, but in the end, there is STILL no official medical organization in the world that recommends routine infant circumcision, including the American Cancer Society.  Here is a recent article that discusses some of these concerns: http://www.nytimes.com/2011/08/23/health/23consumer.html?_r=1

8) It’s a personal choice. 

Personal choice SHOULD mean that the person attached to the penis should get to choose.  Every man should have the right to decide whether or not he wants the full penis that he is born with.  His mother and father’s biased opinion of his penis should not be the deciding factor before he is even old enough to hold his own head up.  If later in life Nathan decides that he wants to have a circumcision, he can go to the doctor, choose the style, size, and shape, method of surgery, types of anesthetic, and type of post-op pain relief.  If he had been circumcised, he could never undo our decision.  Nathan's father reached the conclusion early on in these discussions that he was wronged.  He now wishes that he was not circumcised and while he is not comfortable speaking out against circumcision the way I am, he fully understands that it is unnecessary, that there are clear benefits to having an intact penis, and that parents should not be allowed to make this decision for their sons unless there is a medical reason to intervene.  And really, that's why most anti-circumcision advocates speak out...this isn't just about making a decision for your son, it's about taking away his rights to decide what he prefers based on HIS personal experiences, not ours as parents, which are greatly affected by the culture we grew up in, a culture that has already changed drastically.  It never even occurred to me before beginning this research that there are men who wish they were never circumcised and I was shocked when someone had me run a search for "foreskin restoration" online.  There are a large number of websites discussing ways to get some of those protective and functional features that the foreskin provides back, proving (along with forums filled with men upset about having this decision taken from them) that there are an incredible number of men unhappy they were circumcised.  So, while you may believe you've never met a man who wishes he wasn't circumcised, there's a decent chance you have and he just has no interest in discussing it with you.  While the true foreskin with all of its nerves and inner mucosa can never be replaced, there are ways to regenerate skin to protect the glans.  The Penn & Teller episode on circumcision delves into this in quite a bit of detail:

http://www.liveleak.com/view?i=416_1218124584

9) It is better to have it done at birth because it is much more difficult to have a circumcision later in life. 

To the contrary, the older your son is when he is circumcised, the better the pain relief and recovery can be controlled and the less likely that errors will be made since the penis will be larger.  Infections aren’t likely to be as much of a problem later because the foreskin will have already separated from the glans naturally (the glans won’t be raw and vulnerable to infection) and his immune system will be more developed.  Some people say it’s better to have the circumcision done in infancy because when they are older, they will have to undergo general anesthesia, thus it is a more complicated procedure due to prep time and the inherent dangers that come with anesthesia.  I find this a very disturbing rationale since the reason infants don’t get general anesthesia is because it is too dangerous at that age, not because they feel less pain. 

I’ve also heard people use the reasoning that recovery time is longer and more painful for an adult.  Recovery is about 2-3 weeks for both infants and adults.  During that time, an adult has far more options in terms of pain relief (and the ability to verbalize the extent of that pain) and their wound isn’t being exposed to runny feces and urine in a diaper.  An adult will probably experience the additional frustration of not being able to be sexually active until fully recovered. 

While there are attempts to restore the foreskin, circumcision cannot be undone.  It is a permanent decision.  I’ve come to the conclusion that any permanent, non-medical surgery should be delayed until the child is old enough to make his own, educated decision.

10) I want to have it done now because my son won’t remember the pain. 

There have been plenty of studies showing that there is lasting psychological damage that can occur from the trauma an infant undergoes during circumcision.  This damage includes trust and attachment issues, problems establishing breastfeeding, as well as reduced pain tolerance over the long-term.  Although I personally found these things too subjective to sway me one way or the other, given the rest of the arguments, it’s just not worth the risk.  Another thing that bothers me about this issue is that I can’t help but think that we are simply convincing ourselves that the pain an infant feels is not real or just somehow taking advantage of this pre-bonding period to let our child deal with the pain.  A two-year old won’t remember being circumcised either, but can you imagine not providing adequate pain relief during circumcision to your 2-year old?  I personally do not see how we can compare an adult’s level of pain with an infant’s pain when the infant cannot communicate with us what he is experiencing. 

This argument also typically assumes that an intact child will need to be circumcised later in life.  There are all kinds of anecdotal stories of an older child needing to be circumcised due to infections or other problems, but in reality, the true medical need to be circumcised is very rare.  Almost every case of infections or other problems is caused by forceful retraction...avoid that and chances are you will never have to worry about needing to circumcise your son.  Most boys in the U.S. (and some in other countries I am sure) were forcefully retracted at some point and many still are due to the doctors being misinformed on proper care, so those anecdotal stories no longer have such an effect on me.  Plus, it has become obvious that many American doctors will rush to circumcision as a solution to any problem related to the penis when there is almost always a far less invasive approach available.  Recently, it has been discovered that even with the continued practice of forceful retraction, a circumcised boy has about the same risk of needing to be re-circumcised due to a botched circumcision or adhesions as an intact boy has of ever needing to be circumcised.

11)  My son will thank me for circumcising him before he could remember. 

Yes, this is possible.  But, it's also possible he will resent you for it and as the circumcision rates continue to drop drastically, this is becoming far more likely.  At the very least, this is a very controversial and irreversible decision you are making for your son and if you were wrong about what he and his future partner would prefer, leaving it intact leaves him options.  It's so easy now for someone to go online and do the research themselves.  When my son goes online and sees that this was such a huge debate, realizes the myths about it, and understands the functions of his foreskin, I have no doubt he'll be glad he dodged that bullet. 

FGM A big piece of the circumcision debate is whether or not it can be compared to female genital mutilation (FGM).  I have to admit that at first, I really couldn’t compare the two.  It came across as a really extremist view and I was looking for all kinds of arguments to convince myself that circumcision and FGM have nothing in common.  I was offended that someone might suggest that by planning on circumcision, I was just as barbaric as people who mutilated female genitals.  The moment I stopped looking for ways to disrupt the comparison, I was able to see the big picture.  Keeping in mind that there are various degrees of FGM, whether it is done for appearance, cleanliness, or to reduce sexual sensation, there really are remarkable similarities to male circumcision.   This link shows a direct comparison: http://www.circumstitions.com/FGMvsMGM.html

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I realize that this letter is quite one-sided, but it is my story and the facts have been verified.  I'm not out to mislead anyone, I'm determined to make up for what our doctors are failing to provide us so that we as parents can make an educated medical decision with regards to surgery on a newborn.  I was completely ignorant on this topic when I became pregnant with my first baby.  I know how hard it is to step outside of the comfort zone of our culture and I am not angry with parents who choose to circumcise.  Not only are doctors withholding details on the risks involved, but some doctors are even scaring us with potential medical risks that have long since been disproved.  I am including a list of links below so that you can verify the facts that I have provided and continue educating yourself on circumcision.

The following are links to official medical associations and their statements on circumcision:

American Academy of Family Physicians (AAFP): http://www.aafp.org/online/en/home/clinical/clinicalrecs/children/circumcision.html

American Academy of Pediatrics (AAP): http://aappolicy.aappublications.org/cgi/content/full/pediatrics;103/3/686

American Urological Association: http://www.auanet.org/content/guidelines-and-quality-care/policy-statements/c/circumcision.cfm

British Medical Association, Medical Ethics Committee: http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp

Canadian Pediatric Society: http://www.cps.ca/english/statements/FN/fn96-01.htm

Royal Australasian College of Physicians: http://www.racp.edu.au/index.cfm?objectid=65118B16-F145-8B74-236C86100E4E3E8E

Central Union for Child Welfare in Finland: http://www.childcentre.info/10595/  

The College of Physicians and Surgeons of British Columbia: https://www.cpsbc.ca/files/u6/Circumcision-Infant-Male.pdf

The Royal Dutch Medical Association (KNMG): http://knmg.artsennet.nl/Diensten/knmgpublicaties/KNMGpublicatie/Nontherapeutic-circumcision-of-male-minors-2010.htm


More links:

http://www.thewholenetwork.org/

http://www.askmen.com/sports/health/15_mens_health.html

http://www.askdrsears.com/topics/pregnancy-childbirth/tenth-month-post-partum/deciding-whether-or-not-circumcise-your-baby-boy

http://www.nlm.nih.gov/medlineplus/ency/article/002998.htm (MedlinePlus)

http://www.mothersagainstcirc.org/ (this is an anti-circumcision site)

http://www.circumstitions.com/ (this is an anti-circumcision site)

http://www.mothering.com/discussions/showthread.php?s=5bf433f99b737d53a492f9189737dacb&t=112410 (Stories from mothers who regret having their son circumcised)

http://www.doctorsopposingcircumcision.org/ (this is an anti-circumcision site)

http://mensightmagazine.com/Articles/Northrup/lovecirc.htm  

http://norm.org/ (Site for men trying to restore their foreskin)

http://www.lcshj.org/circum.html  (Statement on Jewish Male Infant Circumcision and Brit Milah)

http://www.jewsagainstcircumcision.org/

http://www.drmomma.org/2011/08/intact-or-circumcised-significant.html   (This site contains graphic images of the head of the penis in an attempt to explain some of the benefits of the foreskin.  The focus is on how the glans must adapt to being an external organ without the protective prepuce.)

https://members.kaiserpermanente.org/kpweb/healthency.do?hwid=aa41834  (Kaiser Permanente's stance on circumcision)

http://www.liveleak.com/view?i=416_1218124584  (Penn & Teller: Circumcision is BULLSH*T: for those of you who like to laugh through the pain)     

19 Comments
 

Penis Reduction Surgery: Does Size Not Matter?

10/02/2011

27 Comments

 
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By Larissa Boeck

Two pregnant moms are sitting together on a park bench after their birthing class. One mom turns to the other and says, “So you’re getting your son the penis reduction surgery right?”

“Penis reduction surgery?”

“Oh yes.  All the men in my family had the penis reduction surgery done at birth. As a matter of fact, I can’t think of a single man who hasn’t had it done. I’ve asked them what they think and they all say it’s way better.”

“Why do they get it done? I’ve never really thought about it.”

“Well, all the other boys I know of have had it done and I wouldn’t want my son to be the odd one out. If he has the biggest penis in the locker room he’ll get made fun of by all his friends! Girls won’t want to date him once they hear about how big his penis is. I mean it would be cruel to make him go through life with a bigger penis! The smaller ones are so much more attractive.”

“But is that really for you to decide? Can’t he do it later if he wants to?”

“Well it’s a personal decision every parent makes for their son based on what’s best for their family. If we get it done when he’s a baby he won’t remember it, and he’ll thank us for it when he’s older! My husband is glad it was done to him as a baby, and we were told if daddy had the penis reduction surgery then his son should too so their penises look alike.”

By now you’re probably saying to yourself, Penis reduction surgery for infants? What a joke!

Believe it or not it’s the most frequently performed surgical procedure in the United States. If you haven’t caught on by now we’re talking about neonatal circumcision. All the commonly believed benefits about circumcision sure sound great. It’s “cleaner,” they say. He’ll have “fewer infections” and “he’ll fit in better.” Sure, when you put it that way, who wouldn’t want to be circumcised? But suppose we called circumcision what it really is- a penis reduction surgery. Does it still hold the same appeal?

It’s one of the most commonly asked questions we hear from insecure men: Does size matter?  Clearly it does, in today’s society anyway. Regardless of your age or gender if you check your spam filter on your email you probably get advertisements daily for “male enhancement” drugs. So in a world obsessed with penis size, why oh WHY would we inflict a surgery upon our sons that reduces the size of the organ? Because that’s exactly what circumcision does. The tissue removed during circumcision comprises roughly 50% (and sometimes more) of the mobile skin system of the penis. If unfolded and spread out flat, the average adult foreskin would measure about 15 square inches - the size of a three-by-five index card. That’s a lot!

In 1995 Australian researchers were measuring the penis size of one hundred fifty participants to better understand condom sizing. An unexpected outcome of the research was discovering the difference in size between circumcised and intact erect penises. They found that circumcised penises were an average eight millimeters shorter than their intact counterparts. Circumcision also meant a reduction in girth of the penis by an average of two millimeters behind the coronal ridge and four millimeters at the glans. (1) Physical size is not the only thing lost in circumcision. An estimated 20,000 fine touch nerve receptors are lost, along with the ridged band, blood vessels, rolling action of the prepuce, and much more. Above all the right to a whole body and the ability to have sex as nature intended is forever gone. 

Would you sign your son up for a smaller penis?

 

(1) Richters, J., Gerofi, J., & Donovan, B. (1995). Are condoms the right size(s)? A method for self measurement of the erect penis. Venereology, 8, 77–81.

Upload the PDF for the study below:
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27 Comments
 

Penile Adhesions: What They Are & How to Deal With Them

09/16/2011

5 Comments

 
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You've heard of penile adhesions following circumcision, but how should they be properly taken care of? 

Adhesions (or skin bridges) are the result of two raw tissues healing together. With circumcision, the cut skin will try to heal back and can possibly attach itself to the penis, creating a skin bridge. This is why some doctors recommend putting Vaseline on the glans for a week to ten days after circumcision (which will prevent the two structures from reattaching.) But what happens if this doesn't work and adhesions form?

It is likely that your doctor will advise you to rip the tissues apart, which can cause pain, bleeding, and scarring. It may be best to see what his reaction is before attempting to do this. If it's painful and traumatic for him, it would be best to leave it alone for now. We're learning that adhesions can sometimes resolve themselves as the boy approaches puberty and begins to 'fiddle' with his penis. In boys that are not circumcised, the foreskin will start to separate as the boy pulls on his foreskin (boys pull the foreskin out and away from their bodies, not toward their bodies.)  Note: only the boy himself should be the one pulling. Everyone else (doctors, parents, etc.) need to leave it alone.

If the adhesions do not resolve on their own by the time the boy approaches puberty, topical creams can be prescribed which will weaken the tissue and help break down the adhesions. If the topical creams do not work, the adhesions can be lysed after the boy goes through puberty (18-25 years) when his penis is done developing. At that time, he will also be able to understand what is happening to his body and can have proper pain medication. Of course, if problems develop prior to puberty, they would have to be dealt with when they present themselves.

The important thing to remember is: adhesions do not need to be immediately dealt with in young children or forcefully ripped apart. As said before, it is possible that the adhesions can resolve themselves. Do not feel pressured by anyone, even your doctor, to take immediate action. If needed, get a second opinion from an intact-friendly doctor first.
5 Comments
 

Pressure from Spouses: A Botched Circumcision Leads to Regret

09/07/2011

28 Comments

 
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A mother shares about the pressure she received from her spouse, and how her son's botched circumcision caused her to regret going against her instincts. 
Posted with Permission from Author

When I found out my second child was a boy, I started immediately thinking of the differences I would find in parenting and care-taking between him and my first born daughter. As I sat at lunch one day with my sister and mother, my sister asked me if I planned on circumcision. We sat there talking and she informed me if she could go back, she wouldn’t do it to my nephew. My mother agreed, stating that if she had had the choice all those years ago, she doesn’t think she would have done it to my three brothers. I was unsure, however; I don’t have a penis, never had to care for one, never knew anything different than circumcision. But I was young. The world was changing. So I did what any reasonable young mother would do. I researched.

I googled everything I could think of, day and night. I watched videos, read articles, looked up scientific facts on pros and cons. I blogged and tweeted my concerns, asking for help making this decision from friends, family, and even strangers. In my heart I knew it was wrong, I couldn’t find any reason to justify it, but I also struggled finding a reason to justify not doing it to my husband. He was convinced it had to be done, that it was cleaner, that it was easier to care for, that it was the natural thing to do. My son would look different than his peers, he would look different than his father, and women wouldn’t be attracted to it. I tried to show him the research, I tried to discuss it, I tried to show him the videos, but to no avail. I couldn’t convince him and I was tired of fighting. Finally, someone gave me this advice, “If you’re still unsure and it’s that important to your husband, just let him decide, even if you don’t agree on it.” So I did. I relented and said, “Fine, dear, have it your way.”

The days and weeks leading up to the birth of our son, I still tried, without luck, to make my husband reconsider. Not even reconsider really, but to just consider another option. He wouldn't watch the videos and stated plainly that I had no idea what owning and cleaning a penis entailed; it would be much more difficult if he was left intact. Did I really want that?

My son was born early on a July morning, and by the afternoon the nurse came around to ask if we were choosing circumcision. I was alone in the hospital room at this point and nearly told her no, to leave him alone, but instead I choked out a yes and was told that he would be picked up tomorrow morning for his “procedure.”

The next day, I sat; silently praying they wouldn’t show up, that they would forget about us, about him, about his penis. They allowed me to finish nursing while they described the way it would happen, what they would do to soothe him and had me sign the forms with a shaky signature. They promised it wouldn’t be more than an hour- two tops. He would come back, right as rain.

I sobbed as they wheeled his little bed away from me.

Five hours later, I awoke from a nap to my husband standing in the room, questioning where he was. I didn’t know, they took him away this morning and I hadn’t seen him since. He walked to the nursery to question the nurses where they explained that he had bled “just a little more” than they were comfortable with, so they kept him a little longer just to make sure.

“You’re lucky!” The nurse laughed at my husband. “Most babies are way too small and the doctors have a lot of trouble getting the whole thing off. You have a big boy!”

For days, my son slept. Not the sweet, peaceful sleep of a newborn, but a fitful, obviously painful sleep. When he awoke, he screamed in pain, unable to be soothed, unwilling to nurse or cuddled closely. He screamed when he urinated or defecated; he was only happy when his diaper was off, but so long as his penis went untouched. I lived in fear of diaper changes. I wanted nothing more than to just leave him be; no diaper, no pulling his penis to ensure the foreskin wouldn’t grow back, no Vaseline on the base. Just freedom from pain is all I wanted for him. We both sobbed during those moments, his diapers always speckled with blood and his face always tear stained.

The healing process never seemed to end. As he got older, the bleeding stopped, but the wound never healed. At first, his pediatrician told us to continue to just put the Vaseline on it, continuing to treat it like we always had. It wasn’t until six months of questioning did she inspect a little better and found that, while the doctors considered him a “big” boy and claimed to have no trouble with his circumcision, they actually snipped too much off. Now, he will have a permanent scar about a half of an inch long at the tip of his penis. When it will become a scar, I have no idea (as of right now, it’s still an open wound, 14 months later.) We’re still required to keep Vaseline on it several times a week. We find blood occasionally on diapers and hear him screaming at the first sign of a dirty diaper. He runs away after his diaper comes off and holds himself sobbing. During those nights when his cut reopens, he and I both lay awake at night crying, wishing for an end.

We should have allowed him that choice, we should have waited. If we had, he wouldn’t be in pain several times a month... he would be whole with no pain, as he should be. I don’t know if this has changed my husband’s view on circumcision, and I don’t blame him for this. I blame myself for saying yes; I blame myself for signing those forms; I blame myself completely, and I will fight for tomorrow’s sons- whether they are my own, my nephews, or a stranger's. No boy should have to go through this pain, not for his parents peace of mind.

28 Comments
 

Proper Care of the Intact Penis (From Baby to Teenager)

09/03/2011

3 Comments

 
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A closer look at the care of the intact penis and proper hygiene as he grows older.

The male foreskin is fused to the head of the penis at birth (just like the female foreskin- the clitoral hood- is normally fused to the glans of infant and young preadolescent girls). This is the body's way of protecting the genitals against urine and feces. Because it is fused shut, bacteria and other foreign particles cannot invade. 

It is absolutely unnecessary to forcibly retract the foreskin to clean under it, and in fact- this will cause bleeding, scarring, and damage to the penis. Pulling it back before it is ready can also introduce foreign bacteria which can lead to infection.

The first person to retract a boy's foreskin should be the boy himself. Everyone else- hands off. The average age for this to happen is about 10 years old. About that time, the foreskin will start to become detached (although sometimes it is sooner, and sometimes it is later). Until about puberty, the body isn't producing anything that needs to be 'rinsed'. So if he gets especially dirty, sitting in a warm water bath (without soap) should take care of the cleaning. Once he can retract his own foreskin, he just needs to pull it back during a shower, rinse with warm water, and return it to the original position. No soap & no scrubbing under the foreskin.

Occasionally, parents might notice the tip of the foreskin being red or inflamed. Don't worry! This is common, and depending on the cause, can resolve itself very quickly. Please read this article on red foreskins in children to get more information.

If child has been forcefully retracted, the best thing to do is stop retracting and let it heal. Please click here to get more information on what to do now and how to clean. Putting a boy into the bath several times a day helps. The body, air, and water are the best healers. Of course, you must be vigilant about watching for infection beyond the initial inflammation for the first week following forcible retraction.
3 Comments
 

Circumcision: A Jewish Mother Has a Change of Heart

09/01/2011

10 Comments

 
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A personal story from a Jewish mother who finally researched circumcision, and had a change of heart once she learned the facts.

Written by: Rebekah C. on her 
Thoughtful Momma blog
Posted With Permission from Author

Circumcision is one of those issues that has moms flaring at the nostrils and screaming in protest regardless of how they personally feel about the issue. I remember the first time someone challenged me on the topic and how furious I was when she suggested I was advocating for infant mutilation. I was, to put it blandly, enraged.

I grew up being raised in a blended faith. My family are Messianics: Jews who embrace Jesus as the Messiah promised in the Tenach. I remember my youngest brother’s Bris quite well but because his Bris was a reception only (the actual procedure was done in the hospital), and the only other one I’d ever been to happened when I was so young I couldn’t really remember it, I had no idea, really, what circumcision entailed other than my parent’s sublime explanation: “It’s when a little flap of skin is cut off as a sign….”

Years later, I married a man who wasn’t circumcised. Not to go into too much private detail but I will tell you that I thought it was so COOL he wasn’t. I had this idea that it made him unique, almost exotic. I laugh a little at myself now, of course. I have only ever “been with” my husband so it’s not as if I had anything at all to compare it to and now, of course, it seems ridiculous to consider something entirely normal as “exotic”.

However, as we talked here n there about our faith, future children, that sort of thing, circumcision came up a lot. At that time in my life, I truly believed that our son(s) needed to be circumcised. That not doing it to him would be a sin. For me. Not him, for me and for my husband.

I am explaining this to demonstrate the backwards and completely blinded point of view I had at that time. When I conceived my first child, I still felt that circumcision was just something I had to do. Thankfully, she came out without a penis, lol. I deeply cared about my child and had she been born a boy I would have had her circumcised believing I was doing the very best thing for her physically AND spiritually. I wasn’t any less of a loving person then. I haven’t become more intelligent over the last 6 years, either.

That said, I was definitely thinking backwards. See, I would never have dreamed of asking my husband to be circumcised. If asked, I would have explained why by saying that it was his body, not mine, and that the decision to cut himself was between him and God.

Are you catching the discrepancy here? It wasn’t ok for me to ask a grown man to choose for himself but it was entirely ok with me to make that decision for my defenseless baby?!

Then, one day, when my oldest was about a year old, I become involved (to my embarrassment, now) in a flame-war going on in a wonderful little yahoo-group that revolved around birthing. As I’m sure you can imagine, mother’s are vicious and don’t really pull any punches when they are advocating their motherly choices for their children. This little war was epic, yes it was. Someone had posted an informative link regarding circumcision awareness and someone else had immediately retorted about being judged and it went off from there. I kept my mouth shut at that point as my personal opinion was that circumcision for any reason other than religious was stupid. But then, the fateful words hit my inbox: “Mutilating your son in the name of your god is still wrong, regardless of your religion.” Ooh I was hot! SO angry. It was like someone punched me in the stomach. How DARE this woman comment on something so intimate and personal as another person’s religious beliefs! I’m afraid I wasn’t even really “hearing” her point, I was just pissed she presumed to know another person’s heart when making decisions like this. 

Looking back on it, she didn’t say anything cruel or intentionally insulting, she was just speaking the truth. But it was ON in that moment. I wrote a lengthy, heartfelt, passionate response. She returned it with one of her own. She made me look like a complete idiot without even trying because she had all this “information” about what was done and it’s life-long implications and I realized I had no idea what I was talking about! So I set about researching her claims, intent on digging up the opposite research to shut her up.

That isn’t what happened, though. I had been told growing up that the anti-circumcision movement was “the Enemy’s” attack on God’s people. That it was anti-Semitic, etc etc. And I was convinced that I could prove her wrong by going to science. After all, wasn’t it true that being circumcised was healthier? I mean, obviously she was just bigoted or misled…right? RIGHT?

Nope. No, in fact, every click I made drew me further and further into an education I didn’t even know I needed. I learned, for the first time in my life, what a foreskin really was and how it compared to female anatomy. I also learned about other forms of ritual genital mutilation that are NOT socially acceptable but defended with the exact same arguments as what I was using! (referring to Female Genital Mutilation, here) I watched circumcision videos (not for the faint of heart, let me tell you! I cried…a lot). I read medical websites devoted both to defending the practice and ousting it as an outdated unnecessary and yes, harmful procedure. I learned things I never dreamed could be true, including that just as many baby boys die during the neonatal period of their lives from being circumcised as do from SIDS. THAT interesting fact spurned me to learn even more and by the end, I was a changed person. I was humbled and I had some serious thinking and soul-searching to do.

I, like so many others, looked for ways around the religious “need” without actually denouncing circumcision. I researched “gentler” ways to remove the foreskin from the son I hoped for, even going so far as to consider doing it myself so that it was done “Biblically” and with the least amount of harm possible!

It was then, when considering doing it myself that I realized that I had lost my friggin’ mind! I mean, I’m sitting there, considering cutting a piece of my son off myself in order to protect him from harm!?!?! What was WRONG with me? I came to the conclusion that there was something seriously wrong with my thinking. My husband, of course, had been going through his own thoughts and research about it and obviously, being uncirced himself, came to the same conclusions. It was a relief, in a way, but posed other issues for us. Concerns about “sin” and about rejection from my family (who still see this as something sacred and necessary). I’ll come back to my thoughts on that at a later time, though.

I’m happy and even proud to say that now I have a 13mo old baby boy who is happily and blissfully ignorant of what he’s been spared. His body was left intact, as it was designed and functions normally. It may be that someday he’ll grow up and, for his own reasons, decide to get circumcised. I admit that as his mother I hope he doesn’t: I think he’s perfectly created just the way he is and it would be a real shame to mutilate a part of his perfect little body. But it’s his decision ultimately, and that’s what matters. HIS choice. Not mine.

I share all of this because I want people to understand that I get it. I know how complicated and difficult this “choice” feels because I’ve been there. I’ve agonized over it, defended it and seethed when anyone contradicted my perceptions of reality.

I really want to talk about this more, it’s a subject I’ve come to feel very passionate about. I want to help stop this horrible practice and help other parents to wake up and see what it is we’re doing! I realize this topic will piss people off. For a long time I hesitated to write about it because I don’t really like intentionally offending people. Unfortunately, though, the truth is the truth. Sometimes hearing it angers people. That’s ok. If someone hadn’t offended me, my son’s little penis would be mutilated today and I sincerely hope that I can share that gift of “enlightenment” with someone else.
10 Comments
 

California Politicians Make False Claims that Circumcision is Beneficial

08/31/2011

8 Comments

 
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The California Senate passed bill AB768 37-0 without debate. The bill states: "Infant circumcision has a wide array of health and affiliative benefits". This statement directly goes against what every major medical association in the world has stated about circumcision.

These false claims need to be addressed. Medical organizations are the ones responsible for making these types of claims, not politicians who have no medical background whatsoever. Even the American Academy of Pediatrics (AAP) takes a position of not recommending circumcision. Consistent with all previous AAP reports, no proven, actual benefits for circumcision are found. The same is true for all medical organizations in the world.

Please, write to the California governor and let him know what you think about these false claims. You can contact him here. Below is an example of a letter that was sent (thank you, Cassandra!)

Hello Governor,

I'm writing to tell you I am strongly opposed to this bill, AB 768, and I ask that you carefully look over it's claims. The claims made in this bill, such as that circumcision has health benefits, are not in par with the rest of America's health organizations, or the recommendations of various health organizations around the world. There are no potential benefits that justify cutting off bits of genitals from unconsenting people. Absent of a real medical need, it is illegal and unethical to perform surgery, cutting off a healthy body part, on an unconsenting person. The only person to choose circumcision should be the person who has to bear it's consequences. Genital cutting (euphemistically called circumcision) is a crime.

The medical code that is often used for circumcision surgery (ICD-9-CM Diagnosis Code 605) is "redundant prepuce and phimosis." There is no such thing as redundant prepuce and it is not possible for infants and children to have phimosis, as the foreskin is fused to the penis in infancy and not supposed to be retractile, that is the normal, natural state. It is not a birth defect and it is not grounds for surgery.

There are documented cases of accidental partial or complete amputation of the penis during "routine" infant circumcisions, why should that be a choice a parent can make with risks like that? Nobody has to live with that except the boy who did NOT ask for circumcision. There are documented cases of babies DYING from circumcision complications. Why should we be risking the lives of children for a surgery that is medically UNnecessary (as stated by every medical organization in the world, including the American Academy of Pediatrics)?

I plead with you to take the time to read through this list (link below) of various medical organizations around the world for their recommendations on circumcision. It would be a grave mistake for America to enact into law a bill that stated circumcision has any real medical benefit when the rest of the world, and even our own AAP, states it is medical unnecessary.

Thank you for your time and consideration.
Cassandra S.

8 Comments
 

Expecting Moms: Trust Your Gut, Don't Make the Cut

08/28/2011

2 Comments

 
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The above image is full of real moms and real comments. Why is this happening? Why are moms going "against their guts" when, if they only knew, circumcision is completely unnecessary (and also dangerous?)

We decided to ask thousands of moms, "Are you a mom who reluctantly had your son(s) circumcised? Did you go against your heart, or were you pressured into it?"

Just a mere sample of the responses:
  • Jennifer writes, "I had my son circumcised, even though after I had him I felt like it was wrong. Every time I thought about it I would cry, but I went through with it anyway because I felt like it was something I had to do."
  • Bianca writes, "When [my son] was cut, we didn't know there was anything wrong with circumcision because no one ever said anything about it to us."
  • Kim writes, "I did. I wish that I had known the procedure as well and all the functions of the foreskin. I could go on and on but I try to tell all I see and hope they will listen."
  • Kellinjoe writes, "[I wish someone would have told me] literally that it just did not HAVE to be done, that half the boys his age were not cut, that would have made all the difference at first. Then knowing first hand as a woman what it does to sex...well that lead me to intactivism (and a broken heart) and all the other stuff just floored me. I hate how little I knew then and how little the people advising me knew."
  • Samantha writes, "My sister's boyfriend convinced her to do it since he and the older two were cut he didn't want the new baby to feel like he was different. She regrets it now because they did it wrong and he will have to have it fixed when he gets older they said."
  • Brandi writes, "I only wish I had been told that I didn't have to do it, and foreskin is NOT just skin. That it would HURT my baby. If that nurse had just said "It's really not necessary" I'm sure I would have at least thought about it before I handed my child over :*( I will never forgive myself..."
  • Christine writes, "I wish my mom hadn't lied to me, it IS more than "just a little snip." I wish my midwives weren't so "hands off" and out of my business and said something, I wish someone had made me watch a video of it being done. I wish my husband didn't... think just because it was done to him that it was ok to do to his son. I wish I hadn't fought my instinct. I wish there weren't other moms there in the office with me also getting their sons cut joking around like it was no big deal. I wish the nurse there wasn't Jewish and so supportive of the cutting. I wish I hadn't focused so much on my natural birth that I didn't educate myself more about circumcision. :'(
    But, because of all of those wishes, I have a second WHOLE son. Lesson learned. Tell your friends, circumcision is more than just a cut!"
  • Elizabeth writes, "I had my first at 17 and had not been told 1 SINGLE thing about circumcision. I just thought it was just what you were supposed to do, and I never once even thought about not doing it. My second son is intact, and any future son(s) will be. I wish someone had given me the facts about circumcision so I could have made the right decision."
  • Crystal writes, "I wish someone had shared SOMETHING with me about circumcision, anything, especially all the bad things. No one said anything, the only thing I could get out of the doctor is that it isn't medically necessary. I wish I had stuck with my gut. I was in a complete panic when they took him to do it, I felt like I couldn't say no... it's very strange to think about. Watch a video, do your research, there ARE choices, let you SON choose."
  • Tom writes, "I wish I had realized that three doctors could look you in the eye, and lie about your kid's situation, and what could be done about it. They were utterly ignorant about human anatomy. They told me he would have phimosis for the rest of his life, and just keep getting infections. That there was no hope for the situation correcting itself. Now, we know that it is normal for the foreskin not to retract at 3. It retracts in its own good time. Perhaps it is time that we fight to get the foreskin put in anatomy and physiology textbooks, so that when a circumcised doctor doesn't know the answer, he can look it up."
  • Holly writes, "I objected vociferously to the circumcision of my oldest two boys, but my (now ex)-husband insisted. The truth is that I wish somebody would have talked to him. We moms talk about circumcision a lot, especially when one of us is pregnant with a little boy! But what we really need is to get the dads talking, and they tend to be silent on that. I think that he would've agreed not to circumcise if one of his (male) friends had said, "Yeah, we decided not to circumcise our little one. I just figured that it doesn't really have a purpose to circumcise him, and frankly, it can't be comfortable for the baby!" Actually, ANYTHING. I just feel like if a male friend had spoken with him about it, maybe he would've agreed not to circ."
  • Birthing Haven writes, "I had my son done when I was 21. I did NOT know better. Although when the nurse came into get my son my heart screamed at me not to let him go. I ignored my heart. My advice listen to your heart and PLEASE do research on it."
  • Alexia writes, "I was pressured/conned into it. And I didn't really know about it, it just felt wrong. No excuse, I am a mother and should have gone with my instinct. If I ever have another son I will announce to everyone and be proud that he will remain whole like his older brother should have been.
    I would listen with sympathy to another mom and tell them I was there once. I was stupid to listen to other peoples opinions. I would tell [another mom] to follow her heart!"
Brooke, mother to two boys, circumcised her first son and kept her second son whole. She wrote a story of how she was guilted into circumcising her first son, and how the circumcision quickly turned downhill. Here is an excerpt from her story:
   
"...His father was all for circumcision but I put up such a huge fight he just let me have my way. My dad wanted him to be circumcised as well but I just ignored him the best I could. At the time of Lance's birth there was quite a lot going on in my life. My grandmother was dying from brain cancer. She passed away five days after Lance was born. I was extremely close to her and like to think of her as a second mother to me. She was home on hospice and we took care of her 24/7. So I was beyond stressed at the time.

The day after Lance was born someone said something so very hurtful it made me question keeping him intact. After he left I cried for hours. It hurt my heart. After my Grandmother passed we had to travel for her funeral and while we were out of town I decided I couldn't risk my son hating me so I was getting him circumcised when I got home.

I called and made the appointment, and my aunt and I took him to get circumcised.We got there what I remember to be about 11 in the morning, we waited a few minutes and then a nurse called us back. She took Lance from me and told me to go back to the waiting room and that she would be back in about twenty minutes. So we sat down and waited, and a few minutes later she came and called us back. There were two big double doors to get to the back of the office where the rooms were. As soon as she opened one of the doors I could hear Lance screaming. I was in shock.

She took us in the room and I almost hit the floor. There was my beautiful, perfect baby strapped to a board screaming so very hard he was purple, couldn't catch his breath and his hands were so tight his knuckles were white. I rubbed the only place I could, his forehead. I stroked it and told him I loved him and he would be ok. The nurse just kept saying over and over, “He's gonna be fine.” She made me feel like what I was doing was wrong, like I shouldn't be trying to console my baby.

The doctor was in the room but he didn't say anything to me, just left the room. The nurse then said she couldn't get him to stop bleeding. She asked my aunt to hold pressure while she left the room to get a Styrofoam band to wrap around his penis to try to stop the bleeding. After she applied the band she put his diaper back on and once again told us he was fine and we could leave so we did. We drove the forty-five minute drive home. When we got back into town I stopped by my mom's office where she worked as a nurse to tell her about it. She told us to go on home and she followed to look at it. When she took the diaper off Lantz it was completely and utterly full of blood. She looked at me and said, "We're going back now."

Read her entire story here.

If you're an expecting mother, or plan to have children in the future, circumcision is something that you need to research. Find support groups online and talk to other moms (or dads) who have been in your shoes. Read the studies. Find the statistics. Most importantly, listen to your gut.

If your motherly instincts tell you it's wrong, it probably is.
Research circumcision to find out why.
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Ryan McAllister on Child Circumcision: The Elephant in the Hospital

08/26/2011

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written by: Larissa Boeck

Ryan McAllister Ph.D. is the creator and director of NotJustSkin.org. He’s also a writer frequently featured on Examiner.com, and currently he’s the intactivist world’s newest YouTube sensation.

At first glance McAllister looks like your average approachable guy next door. In his video presentation Child Circumcision: an Elephant in the Hospital, he is dressed in casual attire. His relaxed posture and his gentle voice have a way of setting you at ease. He addresses his audience the same way he might address a friend at the dinner table, with compassion, humor, and blatant honesty. Only minutes into his lecture you inevitably find yourself hanging on his every word.

“I’m going to talk with you about circumcision,” he explains. “I’m calling it the Elephant in the Hospital because it’s this huge thing that happens, as far as I see, in our culture but we have very little discourse about it. It’s performed between five hundred thousand and a million times each year in the U.S. almost entirely on infants within the first three days of life. It’s completely unnecessary and I believe, based on my research, entirely harmful to children.”

Over a span of thirty-three minutes time, McAllister goes on to examine:

-The most common rationales used to defend infant circumcision

-The history of circumcision in the U.S.

-Comparison of female and male genital cutting practices and attitudes

-Surgical and post-operative complications of circumcision

-Functions on the foreskin

-Ethical issues involving informed consent from medical professionals

-Commercial use of infant foreskin

-Emotional impact

-The flawed science behind the commonly cited studies used to promote circumcision

-Roadblocks to ending this cultural practice

This powerful video, which was taped as part of a university course on human sexuality, has to date topped 2,600 hits on YouTube and over 550 likes on Vimeo. It’s been lighting up Facebook pages worldwide ever since its release in July 2011. Already this presentation has proven a valuable resource in the education of expectant parents who struggle with the circumcision decision.  “I have heard from parents that they've chosen not to circumcise children because of it,” says McAllister.
(See a 10-minute version with excerpts here)

Expectant parents aside, who did Ryan McAllister intend to reach with his message? “Everyone really,” he responds. “I think it's an issue for us to address as an entire society. I would like parents, medical professionals, others who care about children, and academics from the many relevant disciplines (gender, bioethics, critical theory, anthropology, medicine, etc.) to be thinking critically about this practice we have in mainstream U.S. culture of cutting children.”

Why does McAllister feel so passionate about routine infant circumcision in particular? “I believe that adults who interact professionally with children have a critical professional responsibility to bring a very high ethical standard to that work. And even more so with medical professionals, who also have a bioethical imperative to found their work in the needs of the children they serve.”

He goes on to discuss why he finds the practice of routine infant circumcision so troubling. “When I have spoken with medical professionals who perform or have the power to stop this procedure, what I've often heard is a discourse that, instead of being founded in the child's needs, generally lacks any reference to the child's needs. Take, for example, the conversation I mention in my lecture with Dr. Landy, the Chair of Obstetrics and Gynecology at Georgetown University Hospital. When a physician of that esteem tells me that she knows that this elective surgical procedure on a minor doesn't make sense medically, I say that gives her an ethical mandate to stop performing the procedure. However, she said that her department will not "be a beacon of light", that they will not stand out by ceasing to perform circumcision. The reason she gave is essentially economic -- that they want to provide circumcision as a service to parents so that birthing mothers don't choose another hospital in which to give birth. And I am deeply troubled by this reason.”

In addition to all the overwhelmingly positive feedback McAllister has received on his presentation, it’s clear his message has also ruffled some feathers. An attorney representing Georgetown University Hospital issued a letter disputing McAllister’s use of statements made by the Georgetown University Hospital Chair of Obstetrics. McAllister responds: “I have asserted that I am accurately representing my notes from the meeting, and I asked the hospital administration for a meeting to discuss the ethics of their practice of circumcision.”

To date, they have not responded to his request, but according to McAllister that’s not necessarily a bad sign. “My hope is that they will resolve to end the practice because it contradicts the fundamental bioethical principles of non-malfeasance and beneficence -- principles I would hope they aspire to as an institution. As it stands, consciously or unconsciously they're putting the physicians who work at their hospitals under institutional pressure to perform unnecessary surgery on minors -- which, when you look at it, is hard to defend ethically.”

Infant circumcision is only one of many issues McAllister hopes to address. “There are many other elephants in obstetrics -- places where standard practice is directly in conflict with both peer-reviewed research and the well-being of birthing women and newborns,” he points out. “I hope to draw attention to those elephants as well, as the current state of affairs mis-serves women, newborns, their families, and physicians.”
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