Infant's death another nail in circumcision's coffin, group says
Patrick Sullivan
CMAJ
The death of a 5-week-old British Columbia boy 2 days after he was circumcised will further marginalize the procedure in Canada, an international lobby group says.
Dr. George Denniston, a preventive medicine specialist from the University of Washington in Seattle and spokesperson for Doctors Opposing Circumcision (DOC, faculty.washington.edu/gcd /DOC/), described the Aug. 22 death of the Penticton boy, apparently from bleeding-related complications, as "tragic and unnecessary.
"The only good that could possibly emerge is that more parents and physicians will now think twice before proceeding," he said.
Dr. Douglas McMillan, the Calgary-based president of the Canadian Paediatric Society (CPS), chaired the committee that issued the society's statement on neonatal circumcision in 1996 (see CMAJ 1996;154[6]:769-80) and says the statement will be reviewed in light of the boy's death. The statement, which concludes that "circumcision of newborns should not be routinely performed," was reaffirmed by the CPS in March 2002.
In his practice, McMillan tries to convince all parents that circumcision is "not medically in the best interests of the baby," but he says the issue raises strong feelings because "beliefs differ and opinions are strong." He refers the few parents who "still insist" to a family physician.
In a carefully worded statement issued to CMAJ 2 weeks before the infant's death, the Canadian Medical Protective Association (CMPA) said that even though "there is no unanimity in the medical or legal communities" about whether it is advisable or justifiable to circumcise infant males, physicians must proceed cautiously.
The statement, the first the association has issued on the subject, says: "The CMPA advises members that a thorough and informed consent discussion must take place with the parent(s) and must be well documented."
That response came after the College of Physicians and Surgeons of Saskatchewan asked family doctors to stop providing routine elective circumcisions (see CMAJ 2002;167[5]:532).
The procedure's popularity is unknown, but in Saskatchewan it is estimated that 27% of male infants are still circumcised. Denniston says the provinces have helped make it less popular by delisting the procedure — Manitoba is now the sole province covering the cost.
Dr. Robin Walker, vice-president of the CPS and a coauthor of the society's 1996 position statement, says no doctors in his group at the Children's Hospital of Eastern Ontario will perform circumcisions, and he is aware of only one Ottawa pediatrician who still does. In his career he has witnessed several serious complications following the operation, including a case in which a baby "nearly exsanguinated."
The subject raises some challenging legal issues. Last year, the Ontario-based Association for Genital Integrity was preparing a Charter challenge because of a criminal court provision that criminalized female genital mutilation but remained silent about male circumcision. The Canadian Jewish Congress responded that equating the two "is spurious and unwarranted, considering that circumcision is a [minor] procedure" and the move "to delegitimize male circumcision is tantamount to an attack on one of the core religious rituals of the [Jewish faith]."
However, a proscription against circumcision by the medical profession would have little effect on Canada's Jews. A congress spokesperson says ritual circumcisions are usually done by mohels, nonphysicians who are specially trained to perform the procedure according to Jewish law. — Patrick Sullivan, CMAJ
Sunday, October 21, 2007
Infant's death another nail in circumcision's coffin, group says
The circumcision debate
The circumcision debate
I have three young sons and thus far, not one of them has been circumcised—not out of choice but out of indecision. This circumcision issue has actually become a long-running debate between my husband and me. To cut or not to cut, that is the question.
Circumcision is the surgical removal of the penis’ foreskin. For some groups, like the Jews and the Moslems, circumcision is seen as a religious rite. Others see it as a boy’s passage to manhood circumcising young lads at the cusp of adolescence. Still others practice circumcision because of health reasons. We’ve enumerated the various reasons for and against this delicate practice.
You decide.
Issue: Circumcision alleviates phimosis
FOR
A good medical reason to perform a circumcision is phimosis, a rare external congenital condition, which involves an abnormal tightness at the tip of the foreskin. Phimosis may obstruct the stream of urine causing urine to dribble out or spray in different directions. Urine could also accumulate between the tight foreskin and glans making these organs susceptible to infection. Normal sexual development may prove difficult.
AGAINST
Phimosis is an extremely rare condition. What’s more, the foreskin protects the glans from urine, stool, and external irritation. Some concerned groups see circumcision as a cosmetic procedure like ear piercing or lip stretching.
Issue: Circumcision minimizes the occurrence of urinary tract infections
FOR
Several studies of male babies in the 1970s and 1980s conclude that uncircumcised infants and children have a significantly higher incidence of urinary tract infections than circumcised males. The studies assert that the removal of the foreskin facilitates genital hygiene and reduces contamination of the tip of the glans, thus reducing the chances of an ascending bladder or kidney infection.
AGAINST
The incidence of urinary tract infections among uncircumcised male babies is too minimal as to warrant circumcision for all. The best way to prevent infections is to practice proper hygiene habits. Furthermore, circumcision exposes the tip of the penis to urine-soaked diapers that may irritate the glans.
Issue: Uncircumcised men are more susceptible to sexually transmitted diseases
FOR
During sexual intercourse, the delicate foreskin may be cut and bruised leaving uncircumcised men more susceptible to sexually transmitted diseases like syphilis and herpes that spread through breaks in the skin. The cuts may also make uncircumcised men more vulnerable to HIV infection.
AGAINST
Circumcision is not the real answer to prevention of sexually transmitted diseases. Using condoms and limiting the number of sexual partners have proven to be more effective in reducing the occurrence of STD. Even circumcised penises get sexually transmitted diseases. There are a lot of other factors to consider including access to medical care, geographical location, lifestyle, race, and socioeconomic factors.
Issue: Circumcision eliminates the possibility of cancer of the penis.
FOR
Cancer of the penis occurs almost exclusively among uncircumcised men. Some doctors also believe that cancer of the uterine cervix is less common in the female sexual partners of circumcised men.
AGAINST
The incidence of penile cancer is so low that routine newborn circumcision is not warranted. Other factors such as hygiene, family history, and sexual history are equally important in the incidence of penile cancer.
Further, asserting that females with circumcised partners have a lesser chance of contracting cervical cancer seems very far-fetched. There are weightier risk factors associated with cervical cancer such as age of first intercourse, number of sexual partners, possible viral transmission, family history, nutrition and hygiene.
Issue: Circumcision is a safe procedure.
FOR
Circumcision is a simple and safe procedure. Complications such as infection and bleeding are usually minor and preventable. Bleeding can be controlled with pressure or rarely, with a suture. Good hygiene will control infection. Marking how much skin to take off before doing the procedure ensures that the correct amount of foreskin is removed.
AGAINST
Circumcision is a potentially dangerous procedure. Excessive bleeding is the most frequent complication. Infections can occur. And if insufficient skin is removed, the end ring of the foreskin may heal by contracting and thickening, thus producing a phimosis.
Issue: Infants hardly feel the pain of circumcision.
FOR
The pain associated with circumcision lasts only for a few short minutes. Infants hardly feel it. Pacifiers seem to do the trick of alleviating the baby’s pain.
AGAINST
Infants do feel the pain especially those circumcised without anesthesia.
Issue: Circumcision is cost-effective.
It’s a cost-efficient procedure because it results to savings in a national scale by preventing penile cancer and eliminating the need for later, more costly, circumcision or phimosis and infection.
AGAINST
Some health insurers and welfare programs refuse to pay for or reimburse for a routine circumcision. In reality, the cost of neonatal circumcision far exceeds the benefits.
Issue: Boys want to look like other boys.
FOR
Since a lot of newborn males are still being circumcised, other boys want to look like the majority and like their fathers. Other boys might tease uncircumcised boys because the appearance of their genitals is different.
AGAINST
There are a lot more uncircumcised boys now than a few years ago.
Saturday, October 20, 2007
Disputing need for circumcision
Disputing need for circumcision
By Rich Barlow | October 20, 2007
'Such shall be the covenant between Me and you and your offspring to follow which you shall keep: Every male among you shall be circumcised," God tells Abraham in Genesis.
But the head of the Circumcision Resource Center in Boston, which discourages circumcision, said that few Jews perform the procedure for religious reasons and that it is not necessary as a mark of Jewishness.
"Being circumcised is not distinctively Jewish, because Americans circumcise, Muslims circumcise," said psychologist Ronald Goldman, who has written two books on the topic.
Circumcision is common in the United States - the National Center for Health Statistics estimated that 65.3 percent of all male newborns in American hospitals in 1999 were circumcised - but is becoming increasingly controversial. Goldman maintains that the practice can cause physical and psychological damage.
Following are excerpts from an interview with Goldman last week.
Q. What percentage of Jews in America and worldwide circumcise?
A. I don't think anybody has those numbers. Being a lifetime Jew, [I know circumcision is] common practice. There's a lot written about this, historically and otherwise, that supports the statement that a large majority of Jews circumcise. But there's also historical support for questioning circumcision. For example, going back to the 1840s reform movement in Germany, there was a movement to oppose circumcision.
Q. The Bible says circumcision originated as part of God's covenant with Abraham. Forgive the flippancy, but what's your beef with Abraham?
A. I have no argument with religious Jews. They're not part of our audience. They're going to interpret that [text] literally and do exactly what it says. Taking on the fundamentalists - in Christian religion or Muslim fundamentalists - I don't think there's much chance of them changing their views.
Q. So what is your argument?
A. Let's start with the pain. There's strong evidence in the medical literature that circumcision is painful and traumatic. Some infants do not cry because they go into shock. There's research that shows infants exhibit behavioral changes after circumcision. No anesthetic is effective in eliminating pain. The complication rate has been reported anywhere from 1 percent to 38 percent. There's also the fact that circumcision removes a natural, functioning body part. Most circumcised men don't know what they're missing, because they haven't had sexual experience with a foreskin.
There's also an ethical issue. Jewish values place ethical behavior above doctrine, and a growing number of Jews recognize that it's unethical to inflict needless pain and trauma. Who has the right to cut off a functioning body part of another human being?
Q. What about the studies that say circumcision may cut HIV infection rates? Several persuaded the US Agency for International Development to favor it.
A. A Kenya report show[ed] that about 55 circumcisions were needed to prevent one HIV infection, and 54 out of 55 circumcised men receive no benefit.
Q. Given the African situation, where it's fair to call [HIV-AIDS] an epidemic, a one-in-55 prevention rate would save a lot of lives.
A. If you were an adult male and had the option of using a condom and getting virtually assured protection or having part of your penis cut off and getting a 1-in-55 chance of protection, I think the choice is clear.
Q. The counterargument is that we hope our children practice safe sex, but we also know they don't always take our advice.
Would you want someone else to make the decision . . . or would you want to reserve that choice for yourself.
Q. I'd prefer them to make that decision when I was an infant than for me to make it at the age of majority, when it would be many times more painful.
There was a poll that showed some men have strong feelings of anger, shame, distrust, and grief about having been circumcised. That in itself is new information to most people who study circumcision. Most circumcised men seem satisfied because they may not understand what circumcision is. I've heard circumcised men claim that nothing's cut off.
Q. On your website, you cite Hebrew Bible examples of leaders who didn't circumcise.
There is some inconsistency in the Torah around this. But that's not a core argument. I'm not looking to take on a religious discussion about this. Surveys have shown that Jews who interpret the Torah literally are in the 10-to-15-percent range. The bottom line is, let's have the open discussion.
Q. Are you circumcised? How did you get so passionate about it?
A. I am circumcised. I attended a Jewish ritual circumcision in the '80s. The baby screamed at the top of his lungs for 20 minutes. It was one of the most distressing experiences I have had.
Friday, October 19, 2007
German court: Circumcision unlawful personal injury
German court: Circumcision unlawful personal injury
A regional appeals court in Germany found the circumcision of an 11-year-old Muslim boy to be unlawful.
The Sept. 20 decision in a Frankfurt am Main appeals court found that the boy's circumcision without his approval was an unlawful personal injury. The decision opened the way toward financial compensation for the boy.
The case may have repercussions for the practice of ritual circumcision in Germany by Muslims and Jews. The court suggested, in part, that it was a punishable offense to subject one's child to teasing by other children for looking different.
The boy, now 14, plans to sue his father for 10,000 Euro (about $14,000), according to a report by the German ddp press agency.
Reportedly, the boy, whose parents are divorced, was visiting his father during a vacation when his father forced the ritual circumcision. The boy lives with his mother, who had always rejected circumcision. Muslim boys are traditionally circumcised at elementary school age.
According to the court, circumcision can "be important in individual cases for the cultural-religious and physical self-image," even if there are no health disadvantages involved. So the decision about whether or not to go through with a circumcision is "a central right of a person to determine his identity and life."
The court did not give an age minimum at which their parents must seek a child's permission to perform a circumcision . The amount of damages depends, said the court, on the extent to which the boy suffered long-term physical or emotional damage, or "whether his peers would tease him for looking different."
