James L. Snyder (M.D., F.A.C.S.), Past President of the Virginia Urological Society, discusses the controversy around infant circumcision. This conversation was recorded in San Francisco, California on 2010 July 29.
Transcript
(slightly modified)
My name is James Snyder, and I am:
- a Doctor of Medicine.
- a Diplomate at the American Board of Urology.
- a Fellow of the American College of Surgeons.
My particular interest in the field of urology is in the current, ongoing controversy [over the] circumcision of newborn males. In the early 1970s:
- The American Academy of Pediatrics
- The American Urologic Association
- The American College of Obstetrics and Gynecology
all [published] within a very short time [of one another] an almost identical statement that there is no absolute medical indication for routine circumcision of the newborn male [NOTE: By "routine", it is meant that the circumcision is performed on a boy who is already completely healthy]. At that time, I thought that very soon [the practice of circumcision] would dry up and pass away like routine tonsillectomy [(the removal of tonsils from a completely healthy person)], but [such genital alteration] has persisted.
[Routine circumcision is] supposed by some people to be a surgical procedure—it's not, because it's not therapeutic. It's [a surgery-like practice] in search of a rationale; I mean, we're trying to find a reason to do this [to completely healthy children], and new reasons keep popping up when the old ones become discredited.
I'll give you [some examples of the issues that have come up from time to time as a rationale for continuing circumcision (beyond the old ideas of preventing masturbation and curing epilepsy)]:
When I was a student, the current teaching was that routine circumcision prevents cancer of the penis. Well, this is a little bit absurd, because cancer of the penis is one of the rarest of all cancers in men—one half of one percent [(0.5%)] of all cancers in men; [even] in [regions] like Norway and Scandinavia—Europe in general—where [routine] circumcision is almost unknown, [cancer of the penis is still] a rare disease—I mean, one half of 1%; circumcision hasn't reduced it any [in the U.S.], [and] we now have information that cancer of the penis is related to cancer of the cervix in women [in that it's often] caused by a virus called the human papillomavirus [(HPV)] for which we now have immunization (certainly for little girls, and probably in the future for little boys).
Urinary tract infections, which infect 2% or so of newborn [boys]—2 percent!—and that [has been] given as a [justification] for [a] circumcision [rate] approaching 90% or more of [the] newborn male population. [NOTE: Women and girls are many times more susceptible to UTIs than men and boys in general. Nevertheless, nobody suggests performing genital surgery on females in order to reduce their risk; instead, they are treated as necessary with cheap, effective, non-invasive antibiotics.]
The AIDS epidemic. Well, when the AIDS epidemic hit, it was first recognized in the United States in about the early 1980s, and at that time, the sexually active male population of the United States was 90% circumcised. Well, if circumcision has any benefit to prevent AIDS, we should not have had an AIDS epidemic.
It is just absurd to think that something that has failed in the United States could be exported (as it's now being considered by certain people) to Africa—I've heard that there was thought of importing into Africa teams of surgeons and medical teams to [circumcise] populations where [circumcision] is not currently practiced. If it doesn't work in the United States, it's not going to work in Africa.
There's no absolute medical indication for doing a [routine] circumcision. [Doctors] think [they] have consent when [they] get someone's signature on a piece of paper during a rushed obstetric procedure when a mother [arrives] in labor. [Well], that is not really consent; consent is an act of the will—not a [harried] signature on a piece of paper. The other issue is, of course, the [consent of the person] to whom this procedure is [actually going to be] done.
There are people who, when circumcised as children, later realize that they've been deprived of a part of their normal anatomy—their birthright, if you will; one of the very few things that you actually own throughout your life is your body, and part of [your body] is taken when you [are subjected to] routine circumcision. So, some people will grow up realizing that they've lost a body part, and mourn it just as much as they would mourn the loss of an arm or a leg or a finger.
This is certainly a violation of a person's autonomy and his freedom of choice. In fact, one of the excuses given by people who do routine newborn circumcisions is:
You should do it [to him when he's] an infant, because when [he gets] older, [he] won't have it done [to himself].
Well, that of course is the person's right!
- The person's right of freedom of choice.
- The person's right of autonomy.
- The person's right to be left alone.
You can't disguise this violation of a person's right by simply doing [it when that person is a child who] is not aware of what's happening; this is the reason that a number of people are increasingly speaking up against routine newborn circumcision: [It's] a violation of a person's rights and bodily integrity.
There are complications [from] circumcision just as there are [complications from] many other procedures—especially anything that involves cutting or removing body parts. The ultimate complication, of course, is death; there are no statistics on how many children die from circumcision in the United States each year, [but] there are newspaper articles that pop up, [and] I have to say that they probably represent only the tip of the iceberg. There are, in my [estimation], about 200 deaths per year in the United States from routine newborn circumcision; most of these children bleed to death, and that is perhaps the reason given for the death:
They died of “bleeding” or “hemorrhage”.
Occasionally a child will get an infection [due to circumcision]—and this happens regardless of the technique, whether [the practitioner uses] a GOMCO clamp, or a plistibell, [etc.]; plastibells have become infected, and the infected site [on the child's penis] leads to widespread infection and sepsis—overwhelming infection which leads to death.
These are just a few of the different ways that things can occur. There are often bizarre things that happen that are almost [unique] means of death, [and] all [are ultimately] related to the fact that the child was circumcised, [though] the autopsy report will almost inevitably say something not involving the circumcision as the cause of death.
Lesser complications are more common. Again, they are unreported and unrecorded in the sense that nobody can give you any accurate statistics, but as a urologist practicing for over 30 years (since the time I began my training in urology until my retirement in [the year 2000]), I have seen numerous cases where a circumcision led to scarring and what we call bridging, where the circumcision scar [sticks] to the glans penis [(the "penis head")] and creates a little tunnel where skin debris build[s] up and [causes] not only something unsightly but also perhaps difficult to clean and difficult to live with.
The most exaggerated [such case] I would say was a 16 year old boy who had a hernia and came to me with this big bridge that covered roughly a quarter of the circumference of his glans penis; he had this removed during the time of [the] repair of his hernia, but prior to that, he had to live with this for all that time.
I do see adults with skin bridges. I do see adults who had so much skin removed [during a circumcision] that it altered their sexual functioning. Indeed, it decreased or diminished or significantly impaired their sexual functioning. Some of these adults have such [little] skin left on their [penises] that pubic hair migrates down onto the penis [during] an erection; this causes quite a bit of concern because [their] partners find this uncomfortable [and] unacceptable; [some of] the people who had this done [to them] have to resort to shaving [in order] to be acceptable to a sexual partner. This [happens] because some doctors [for whatever reason] just feel [that] when they get a child's penis in their hands[,] removing more skin is better than removing less; throughout my career, when I've had to do circumcisions, [I] always tended to leave as much [skin] as possible [to] reduce the consequences of loss of skin.
The worst thing I would say I've seen as a physician [was when I was] called to the cribs of two infants:
One was a newborn [who was circumcised] by a fully qualified physician who managed to take all the skin off the shaft of the penis but leave the foreskin intact! He did this with an instrument [meant for circumcision] called the GOMCO clamp, which is probably the most commonly used instrument in American hospitals.
[The other] child, at about 7 months of age, [was cirucmcised]. As a last minute... "touch up"... to the procedure, the doctor [applied] electrocautery onto the GOMCO clamp, which is a metal device on the penis during the circumcision, and basically fried the child's penis; over a period of weeks, his penis just died and fell off. He's had several surgical reconstructions, but of course, nothing is ever going to replace [what was] lost due to this surgical mishap:
- The nerve endings.
- The erectile tissue.
- Even the skin.
- The glans penis.
[These tragedies] occur sporadically; I can't tell you how often, but each one is a living tragedy because these people go for the rest of their lives without any possibility of having normal sexual behavior or feelings or emotions, [and it was all due to a surgery that was completely unnecessary in the first place].
The first time I ever heard of [such cases] was when I was at medical school in [the 1960s] in Philadelphia. [There] was a story that went around [about] a famous child: Dr. Money, who was a psychologist (I believe in Baltimore), managed a [boy] who was given sexual reassignment [as a girl] because of loss and injury of his penis at the time of circumcision. This turned out to be a very difficult thing for the child, and Dr. Money documented in the medical literature his experience with this child and the child's own experiences; they were not easy to discuss or to live through, in any case. [NOTE: This is the story of David Reimer, who ultimately committed suicide.]
Varying degrees of complications occur, [but] some people wouldn't even recognize [these] as [complications], especially [with] skin bridging. [However], urethral injuries occur, where the clamp that is used for circumcision cuts through the glans penis and removes either the tip of the glans penis or slices through the urethra; this results in a scar at the opening of the urethra (where the urine comes out), and the child is left with an obstruction that may not be recognized and [that] can lead to serious damage of the kidneys.
It can be shown by the statistics that are presented on newborn circumcisions [that Americans] are entering an era where [the] value [of circumcision] is being questioned increasingly; there are a number of states where the funding for circumcision under Medicaid has been removed—probably as the result of budgetary conciderations, but still it's being removed—and when the money [is] removed, the rate of cirumcision [in that state] decreases.
[Americans] are discovering nobody has proved you can't live a normal life without [being circumcised], so I think eventually we'll see a significant number of kids coming into the locker rooms with intact bodies, and they're going to tip the scale in favor of [leaving the foreskin] alone—as nature intended. Like New Zealand and Britain, [we will have] eradicated circumcision within a generation, hopefully.
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