Travis Wisdom, a student of Women's Studies at the University of Nevada, Las Vegas, organized a daylong conference on male circumcision and the issues surrounding identity and body ownership.
The third speaker of the day was Gillian Longley of Colorado NOCIRC, who discussed the unethical nature of non-therapeutic circumcision without valid consent (with a focus on neonatal circumcision). Here is a recording of the presentation, and a transcript follows.
Transcript
(slightly modified)
Eliyahu Ungar-Sargon
From the White Letter Productions studios in Los Angeles, California, I'm [Eliyahu] Ungar-Sargon, and this is The Cut Podcast.
Karoline Khamis[?]
It's my pleasure to introduce Gillian Longley. She is:
The coordinator of the Colorado chapter of NOCIRC (National Organization of Circumcision Information Resource Centers).
A member of the Board of Health Professionals of Intact America, another one of our sponsors.
So, let's give a hand to Gillian Longley. Thank you!
Gillian Longley
All right. Thank you so much for coming today. Travis, thank you so much; this is really wonderful!
So, I'm going to switch the slide immediately to something more interesting to look at while I just introduce myself. We're going to be talking about ethics today, and I just want to give you a little of my background.
I work in a neonatal intensive care unit in a newborn nursery, so I'm around circumcision every day, and I see the realities of the complications, the trauma, the pain, the realities of how little parents know about what they're being asked to decide about, and the realities of how little doctors are telling them about it, and how little the doctors themselves know about it.
So, that's what I'm doing here; there's a lot that needs to be changed in birthing, [and] circumcision is certainly one of them. John?
John Geisheker[?]
[inaudible; laughter]
Gillian Longley
I don't really know; I just love the picture!
All right. Well, anyway.
So, there's a lot more about medical ethics than I'm going to be able to cover in the [time I have]. Has anybody here ever taken a medical ethics class? Are there any health professionals here? OK. Yay. OK. So, I recommend (if you're a student) to take a medical ethics class, because it's really interesting and it's certainly applicable here. There are some extra materials in your packet; there's a bioethics handout from NOCIRC, and then there's a resource sheet that has places you can go if you really want to delve into more information that can tell you where to go for more ethical information.
In looking at the ethics of non-therapeutic infant circumcision, there [are] 2 key questions [at which] we are going to look:
Is it ethically acceptable to alter the natural genitals of a child when no compelling therapeutic reason exists? You would say there isn't any other category of human being [for which] you would say it [is] an OK thing to strap [a child] down and cut off part of [his or her] genitals without permission, but this is what we do [to] baby boys; we wouldn't do it to an adult, we would wouldn't do it to a girl (there [are] federal laws against that), but in [the U.S.], doctors and parents act as if this is an OK thing to do to a boy, [but] medical ethics and the human rights principles [do] not support that [conclusion].
Who is the appropriate person to give permission for elective non-therapeutic cutting of anyone's genitals? Historically, up to a certain point in the United States, it was the doctor [who] made the decision—it was just done: [The] baby came back to the mom, [and] the first time she saw him, his penis had [already] been cut. Then in the 1970s, medical ethics changed to acknowledge that the patient [has] a right to make [his or her] own decisions about [his or her] body; [this was] a change from [a doctor's decision] to now being a [parent's] decision. We haven't gone quite far enough, because actually the person who is the patient—the person whose body is most affected—is not the parent, but [rather] the boy himself.
[In American medical discussions, there is a lot of rhetoric about circumcision being] a personal choice, [but] basically they're [deferring] to the parent's or the family's personal choice, [when] really it's the boy who is the person [who] matters.
Now, I am talking about male infant circumcision here, but the questions that we're talking about—the principles we're looking at—could be applied for female cutting or for genital cutting of intersex patients.
We're going to talk about the principles of medical ethics and human rights; I'm going to talk about:
Ethics of specific common arguments made [in favor of] circumcision.
Informed consent.
Conscientious objection [among] health professionals—that is, refusal to perform circumcisions.
Where we need to go from here with ethics.
So, there are 4 principles of medical ethics that are usually used to analyze a situation, and it's a kind of over-simplified system, and there aren't any clear guidelines [for] how to balance these 4 principles all the time, but it's a helpful approach; it's widely used, and I am going to use some of these terms:
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The principle of autonomy. That calls for respecting the patient's right to freely make his own decisions about medical interventions, and that's typically considered the foremost of these 4 principles, because it's based on a core ethic of respecting the fundamental self-determining dignity of each individual human being, and out of that respect, assuming that [an] individual is truly the best one to make [his] own decision about things that [are] going to impact [his] body—out of [his] own values and preferences.
Now, [as for] neonatal circumcision, obviously the decision [is] being made by the parent. Clearly that decision is overriding the future autonomy of the child to make his own decision about his own body.
Beneficence. [This considers] whether the proposed intervention can reasonably be expected to do the patient any good. Now, [Marilyn Milos and John Geisheker] have talked about some of the medical background here. I think one thing that hasn't been specifically said in the earlier presentations is that no medical organization in the world recommends routine infant circumcision for health benefits. The other thing is [that] even if there were some health benefits, there's only going to be a small proportion of males [who] would ever derive a benefit from it, so neonatal circumcision does not meet this beneficence principle.
Non-maleficence. [This considers] whether that intervention avoids doing unnecessary harm, and we've seen [in the other presentations] that circumcision does do harm physically, emotionally, [and] sexually, and those harms are unnecessary, because there are more conservative ways to gain whatever health benefits you want, like simply washing or [adopting] safe sex behaviors, and those kinds of things.
Justice. This factor is really saying: Is what we're doing fair? Are we distributing the benefits and burdens of health inverventions in society in a fair way? In the case of genital cutting practices, we should be asking the question: Well, are we treating males the same as we are [treating] females? Are we treating adults the same as we are [treating] children? Obviously, the answer is “No.”
On top of medical ethics principles, the United Nations has promulgated a number of landmark statements on human rights, and these also apply to circumcision. [Like] medical ethics, these human rights statements are based on the recognition of the inherent dignity of all human beings, and of the rights that come from that inherent human dignity. It's worth noting that non-religious circumcision as practiced here in the United States got started in the 19th Century, which was before this development of international understanding of human rights, and before the modern articulation of these medical ethical principles.
Circumcising societies like the United States have been behind the curve as far as applying modern human rights principles to something that's already an entrenched cultural practice.
Now, the first of these [United Nations] statements was:
The Universal Declaration of Human Rights
It came out in 1948, right after the founding of the United Nations, and that term “universal” that's in a couple of these titles means:
No exceptions! This applies to everbody! Adults, children, males and females, and so forth.
According to these various statements (and there [are] others that I didn't list), children are understood as having the same rights as adults, but they are also understood as needing additional protections because of their obvious vulnerability, so [the UN published] a specific [statement] in 1989:
Convention on the Rights of the Child
Now, here [are] just some of the rights that are enumerated in these various documents that could be seen as related to circumcision (and there [are] others that I haven't listed here). Article [3] of The Universal Declaration of Human Rights states that:
[Everyone has] the right to life, liberty and security of person.
Security of person in international human rights law [is meant] to ensure the physical integrity of every person being protected. Everyone has the right to:
Property, one's body being one's most essential property.
Freedom from torture and “cruel, inhuman or degrading treatment”.
Equal protection before the law.
The special rights that were enumerated for children include (this is an earlier form of the Convention [on] the Rights of the Child):
The right to opportunities for children “to develop physically, mentally, morally, spiritually and socially in a healthy and normal manner and in conditions of freedom and dignity.”
The right to protection from “all forms of [physical or mental] violence, injury [or] abuse… [maltreatment or exploitation], including sexual abuse”.
The rights of protection from “traditional practices prejudicial to the health of children”, which certainly covers genital cutting practices.
There [are] a couple of other medical ethics texts that are relevant, and I'm going to quote from some of these as we go along, and these are more specific, clinical contexts: The codes of ethics of the various medical organizations (the AMA, [etc.]); there are circumcision position statements from various medical organizations (all those acronyms there). The AAP [is one to which] I'll refer several times. [It is] the American Academy of Pediatrics, and they also have a specific document on the problems with proxy consent in pediatric practice, where parents have to make decisions for children. So, these dovetail with the other things we've just talked about, but there [are] some contradictions between them, which I'll point out.
Impact on Boys and Men
Now, there's a lot of theoretical stuff to ethics, but medical ethics is not just about theoretical words; what it's about is doing the right thing for human beings in medical settings, and circumcision has ethical implications in relation to the human beings [who] are affected by it. Of course, in the U.S., [those people are] boys and men, who are most egregiously affected, [but] women and parents and health professionals are also ethically impacted. So, in talking about the ethics of circumcision, I wanted to give voice to those who are affected by it, and kind of humanize it—make it real.
Now, parents are told that they [must] make a choice for their child, but it's not just making a choice for a baby; it's making a choice for the man that he is going to one day become, and I have a few quotes here I'm going to show you from men who were circumcised as babies—without their consent—and it gives voice to them for their sense of violation that came from that—and not all men are going to feel this way about [having been] circumcised without their consent, but many are troubled to one degree or another, and these quotes will give you an indication of the seriousness of having had this decision taken away from them:
“When you do it to a baby, there's no way back. I'll never know what sex would be like with a foreskin. It makes me angry that somebody else decided for me to do something that I probably would not have done if I [had been] deciding for myself.”
“I have never been able to accept the fact that someone cut part of my penis off when I was a baby; the shear monstrousness of it haunts every waking moment of my life.”
So, again, ethics requires us to consider the impact of our actions on the well-being and the rights of the people who are affected. We could easily sympathize with victims of female genital cutting, who would say something like this, but our culture has kind of led us or programmed us to overlook this type of expression from men, or to deny them, or to belittle them. So, it's very important to remember that the primary stakeholder in the circumcision decision is the man himself—the boy and the man he will become.
So, here's the core statement of the ethical problem:
Neonatal circumcision is a non-therapeutic (medically unnecessary), irreversible amputation of a normal, healthy, functional body part from a non-consenting person.
There's no disease or deformity present in the penis of a newborn baby that requires any kind of decision about surgery, and yet surgery is being offered for whatever social or cosmetic reasons [for which] a parent might think [he or she wants] it done.
Now, amputative surgeries that completely remove or destroy a natural body part are typically viewed as a last resort in medicine, because they are irreversible, and whatever harm [produced] from the loss of that body part is going to permanently alter the person's life with no going back. So, generally, treatments that conserve a body part are typically preferred in medical ethics.
[In] support of the autonomy of an otherwise competent patient, amputative surgeries that remove a normal, healthy body part (such as non-therapeutic circumcision) would be considered ethically OK when requested by a fully informed adult, but non-therapeutic amputations at the request of somebody else other than the person who's having it done to [him] would be ethically rejected almost out of hand, except, again, this is exactly what we do to baby boys every day without giving them any choice about their own [bodies].
So, in the absence of a valid medical indication, non-consenting circumcision violates the person's human right to sovereignty over his own body, and that is a right that is so fundamental that [it's] the basis of assault law, and that's why consent is considered so important in modern medical ethics.
Now, I want to go into 2 of the main justifications that are given by defenders of circumcision, and cover the ethics.
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[The] amputation of the foreskin of newborns might have potential medical benefits.
I want to stop before I [discuss] that, and first I want to point out that there's a basic problem with framing [circumcision] in terms of “risks and benefits”: I've seen parent information handouts that discuss the “risks” of being “uncircumcised”, and what this [verbiage] is doing is pathologizing the foreskin—it's framing [the foreskin] as a problem or a disease ready to happen or some kind of potential medical problem, instead of just the normal body part that it is. But, this is the discourse that our culture has bought into with regard to cutting the genitals of baby boys.
Margaret Somerville, [from whom] I'm going to quote here, is a lawyer and a bioethicist from McGill University, and she has written in this book:
The Ethical Canary: Science, Society, and the Human Spirit
[the following]:
A common error made by those who want to justify infant male circumcision on the basis of medical benefits is that they believe that as long as some such benefits are present, circumcision can be justified as therapeutic, in the sense of preventive health care. This is not correct. A medical–benefits or “therapeutic” justification requires that [overall] the [medical] benefits sought outweigh the risks and harms of the procedure [required to obtain them], that [this] procedure is the only reasonable way to [obtain these] benefits, and that [these] benefits are necessary to the well-being of the child. None of these conditions is fulfilled [for] routine infant male circumcision.
The benefits do not clearly outweigh the risks. There are effective conservative measures for preventing or treating potential problems, and most of the conditions [for which] circumcision is touted [as a solution] do not apply to children, like sexually transmitted diseases. So, in summary, [Somerville] says:
If we view a child's foreskin as having a valid function, we are no more justified in amputating it than any other part of the child's body unless the operation is medically required treatment and the least harmful way to provide that treatment.
With some variations, these same kinds of arguments could be used to debunk arguments for “potential public health benefits” for circumcision, as well.
So, going back to our question number one: Is it ethical to surgically alter the natural genitals of a child when no compelling therapeutic reason exists? Well… no.
Non-therapeutic newborn circumcision by males violates all 4 of the core principles of medical ethics, and a host of human rights principles. Circumcision of a child is acceptable only when medically necessary, and only when conservative treatment approaches have failed.
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It's the parents' right to make this decision for their sons. Indeed, in general in our society, parents are given a wide latitude in child rearing decisions of all kinds, which includes medical treatment, based on the Constitution's right to privacy.
But, remember: The principle of autonomy is considered the lead principle in medical ethics, all other things being equal, and there has to be a good reason for overriding that principle. So, one such case in which [overiding] the autonomy principle could be justified is when there is a true need for medical treatment for a child. Children are not considered cognitively unable to make their own medical decisions; they [neither] are mature enough mentally [nor] have enough life experience to act autonomously on their own. So, in the case of true medical need, the beneficence principle is going to [override the autonomy principle] to protect the child's well-being, and the parents are given, in this case, the role of proxy or surrogate decision makers as guardians of the child's interests.
Now, the ideal standard for a medical decision that's being made for someone who is not competent is what that person would want for [himself]; that's the autonomy principle, and that's what an advanced directive is for an adult—[the adult leaves] instructions: “This is what I want to have done later on when I'm incompetent.” But, with proxy decision making for children, well, we can't really directly know what a child would actually want for himself, so what usually happens is that when a decision [must] be made for a child, the idea of the child's “best interests” becomes the guideline for making decisions. Here, from various sources, are some of the factors that go into determining what may be the child's best interests:
Maximizing benefits, while minimizing harms.
[Considering] both physical and emotional aspects.
Preferring the least restrictive and least intrusive way to get the desired benefits.
Taking into consideration:
Families' views and socio-cultural background.
The patient's wishes, feelings, and values to the extent that you can ascertain them.
The BMA (which is the British Medical Association and the one medical organization that's [taken] a very thorough look at the best-interest standards in relation to circumcision) say [that] one of the things that goes into determining best interest is the prioritizing of options which maximize the patient's future opportunies and choices. So, what the BMA is saying is that consideration must be given for not closing down the patient's future autonomy unnecessarily, even when there is a medical need present. As we've seen with neonatal circumcision, since there's no problem—no decision having to be made—there's really no reason why the child's future autonomy should not be given full consideration.
Now, there are a number of problems with pediatric proxy consent, and for our purposes, I'll just simply say the bottom line is that parents don't own the child; they are actually the guardians of the child's interests, and there are limits on what the parents may do to a child. [Parental] proxy consent is considered appropriate for cases of actual medical need, such as diagnosis or treatment of an actual problem to protect the child's well-being, but there are legal and ethical scholars in the U.S., in Canada, in the UK, and Australia, all who have questioned whether it's legally valid for proxy consent to apply to non-therapeutic procedures. The other thing to remember is [that] it is the child who is the patient, and even though parents are typically accorded the right to make medical decisions, the AAP warns in their proxy consent statement:
In attempting to adapt the concept of informed consent to pediatrics, many believe that the child's parents or guardians have the authority or “right” to give consent by proxy. Most parents seek to safeguard the welfare and best interests of their children with regard to health care, and as a result proxy consent has seemed to work reasonably well.
However, the concept encompasses many ambiguities. Consent embodies judgments about proposed interventions and, more importantly, consent (literally “to feel or sense with”) expresses something for one's self: a person who consents responds based on unique personal beliefs, values, and goals.
Thus “proxy consent” poses serious problems for pediatric health care providers. Such providers have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses. Although impasses regarding the interests of minors and the expressed wishes of their parents or guardians are rare, the pediatrician's responsibilities to his or her patient exist independent of parental desires or proxy consent.
There are some other general problems with proxy consent in that proxies might not all make the best decisions for their wards, and some of the reasons for this is that there's a risk that [proxies] may use their own values or concerns to make these decisions, and there's the risk that they may overlook or minimize the harms of such decisions since it's not their [bodies] that [are] going to be affected. [Also], there are actual studies [which compared decisions made by a competent person and [his] designated surrogate]: Well, they asked the real person what [he] would do for a certain situation, and they asked the [surrogate] what [he] thought [the real person] would do, and it [turned] out that [the choices] were often not the same[,] and [this result] is actually even worse when [it comes to decisions about] elective interventions like circumcision.
Considering all of the foregoing [discussion], what does the [American Academy of Pediatrics (AAP)] say about all of this in their medical circumcision position statement? They say:
In cases such as the decision to perform a circumcision in the neonatal period when there are potential benefits and risks and the procedure is not essential to the child's current well-being, it should be the parents who determine what is in the best interest of the child.
So, what they've done is basically bypassed any consideration of the rights of the child even as they are stating that it's not essential to his well-being.
However, if you look at their proxy consent [position] statement (and this is where the contradiction [comes] in), the AAP does acknowledge the child as a stakeholder in medical decision making. Although they don't explicitly extrapolate these principles to infants, they're really quite applicable to the circumcision scenario. They say:
Parents should not exclude children from decision making without pursuasive reasons.
So, I would argue that there really are no pursuasive reasons for excluding a baby from future decision making about his body. [The AAP also states]:
A patient's reluctance or refusal to assent should also carry considerable weight when the proposed intervention is not essential to his or her welfare and/or can be deferred without substantial risk.
Well, the AAP just said [circumcision isn't] essential, and there is no substantial risk to a child having a foreskin, so I think we should just be also giving the child's future option to forego circumcision some considerable weight.
Now, I just want to compare the AAP's approach to the ethics of circumcision to the way that the circumcision position statement of the Dutch Royal Medical Association (which just came out) addresses it. [The Netherlands] is a country that never practiced circumcision—most countries in the world never have; the U.S. is unique this way.
You'll see that this Dutch statement is much more in line with the medical ethics principles and human rights principles that we've been talking about:
“Insofar as there are medical benefits… it is reasonable to put off circumcision until the age at which such a risk is relevant and the boy himself can decide about the intervention, or can opt for any available alternatives.”
“Non-therapeutic circumcision of male minors is contrary to the rule that minors may only be exposed to medical treatments if illness or abnormalities are present, or if it can be convincingly demonstrated that the medical intervention is in the interest of the child, as in the case of vaccinations.”
“Non-therapeutic circumcision of male minors conflicts with the child's right to autonomy and physical integrity.”—
I don't know why it has to be so difficult for Americans to figure this out.
OK, I'm going to stick it in a little further here: I took [the] circumcision position statements from the Netherlands, Australia, UK, British Columbia, (Canada didn't have anything), the American Academy of Pediatrics, and the American Academy of Family Physicians [(AAFP)], and [considered how each discusses topics] relating to ethics:
[Does] it say it [is] the parents choice?
[Does it] acknowledge the child [is] a stakeholder or acknowledge that the child [is] able to make his own decision?
[Does it] acknowledge the ethical problems?
[Does it] acknowledge legal problems? Perhaps in a couple of cases they may mention that it might be reasonably made illegal, just like female genital cutting.
[Does it] compare [circumcision] ethically to female cutting?
[Does it] acknowledge that health professionals have the right to refuse to participate through conscientious objection?
Of the American position statements, the AAP only talks about the parent's right to choose, and the [AAFP] says:
A physician performing a procedure for other than medical reasons on a non-consenting patient raises ethical concerns.
but they don't talk any further about it.
Our second question: Who's the appropriate person to give permission for elective, non-therapeutic cutting of anyone's genitals? The owner of the penis—the man himself when he's old enough to give his own informed and voluntary consent based on his own values and preferences; [of course], there is no ethical problem with circumcision voluntarily chosen [for himself] by [an] adequately informed [adult].
I just couldn't resist this, because this kind of puts it all together: This is a genital integrity activism poster that highlights that issue of self-determination and choice, and [it] very clearly shows the wrong of forcing unwanted body modifications on a physically restrained and gagged person. Now, it's very easy to see the ethical violation when it's done to an adult, but again in our culture, we're programmed and acculturated to ignore it when it's a baby [boy] whose rights are being violated.
Impact on Parents
Moving on from the ethical impacts on the male himself, I also want to give a voice to the ways that parents are ethically violated by circumcision.
“It was assault on him, and on some level it was an assault on me; I will go to my grave hearing that horrible wail.”
“If only once someone had mentioned [circumcision isn't] medically necessary, I know I would have questioned it, but no one did.”
“I really honestly don't think I'll ever forgive myself for letting this happen to him.”
This is from a YouTube video of a very articulate young mother who did circumcise her son and later came to regret it, and she said she thought she was informed, but she later found out a lot of things she didn't get to consider, which she lists in her video, and she says:
I didn't know it would affect breast feeding, that it would look so gruesome, that it would affect the sensitivity of the penis, that the foreskin [has] a purpose, that [circumcision has] a risk of death—
[She] says that's the one that got her the most when she learned that. “I didn't think that I might possibly regret it so seriously”, and she said that had to do with the irreversibility of what she had done; she says [that] she never thought that he might not want to be circumcised.
So, this leads us to how parents are educated about circumcision and the topic of “informed consent”.
The doctrine of what's called informed consent has only been codified in medical practice since about the 1970s, but it's now considered one of the cornerstones of modern medical ethics. Informed consent refers to the patient's right to agree to (or to refuse) a proposed medical intervention based on an adequate understanding of the implications of his decision. Again, this is based on respecting the self-determining dignity of the individual, and has that practical, beneficence-based function of supporting that patient's interests in making rational decisions, because this is an area where most people don't have a whole lot of knowledge; patients are kind of in a one-down position—they need that information.
So, what are the elements that make a consent valid in a legal sense or in an ethical sense?First of all, consent is only valid if it has been given by a mentally competent person—we talked about the children not being considered competent; [similarly], a person with schizophrenia wouldn't be considered competent. So, then you get a surrogate or proxy designated to give that [valid informed consent].
Second, consent is only valid if it's given voluntarily and autonomously—that is, it must not be subject to coercion (like threats), and it must not be subject to manipulation (like rewards or punishments or deception of some kind). Consent is only valid if it's based on adequate disclosure of any information that would be needed to help the laypatient understand the implications of [that to which he or she] is being asked to agree.
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Finally, the consenting patient must actually understand the information that is being given. [Here are] some of the factors that can impair understanding (and a lot of these are present with newborn babies):
Pain; being on pain medication.
Stress; informational overload.
Complexity of language; the reading level that's used.
Very importantly with informed consent: The amount of time that a person is given to consider [a] decision.
The information that's required to be disclosed for valid consent is typically understood to include information on:
The nature of the health problem—again, there's no health problem with a newborn penis.
[The] nature of the proposed procedure—the risks and benefits of that procedure.
And very importantly, comparable information about any reasonable alternatives to the procedure, so that the patient can make a valid comparison between the relative advantages and disadvantages of [the] options.
The more elective—that is, [medically unnecessary]—the proposed procedure, the higher the level of disclosure that's required; [that] is out of respect for the patient having the right [to consider decisions more carefully] when the intervention is really not clearly necessary.
Now, the inadequacy of informed consent for circumcision has been noted in the medical literature for a very long time, and here are some findings from one of the most detailed studies of informed consent, [which] surveyed both practitioners and mothers in several different institutions back in the 1990s. In terms of process, nearly half of the practitioners that performed circumcisions had not talked to parents about circumcision before the births. Of those practitioners who did [circumcisions] and provided prenatal care, more than a quarter of them never brought it up before the births. Of the mothers, [only] 29% said they had discussed circumcision before the birth with either their obstetrician[s] or their pediatrian[s], and 25% of the mothers (but more than a third in some other surveys) reported that they did not receive enough information to make their decision[s], and yet they were making the decision.
Now, I'm going to go over some content that comes up here, but specifically from this survey, they did find that of parents who requested circumcision after the birth, some physicians that were observed here (some of this was survey, and some of this was just watching what they did and taking notes) appeared to assume that the discussion of reasons for or against it had already been covered, so all they did was explain the procedure and some of the risks, but they didn't talk anything about the alternative of not circumcising.
[Here are] some other specifics of content from some other surveys; this is specifically on complications [of circumcision], and how parents are informed about this. In 2 different surveys, parents were found to be most often informed only of the general risks of surgery, that is: pain, infection, and bleeding. Just those 3. That was the majority of what they were told, but there are dozens of circumcision-specific complications documented in the literature that just weren't talked about.
In another survey, more than 60% did not mention the possibility of damage to other parts of the penis (like the glans), and 92% of the practitioners [who] were surveyed did not mention the possibility of death—which is rare, but it is a real possibility.
Now, I actually did a masters thesis that involved doing a content analysis of parent circumcision information handouts—so, this is why I'm so interested in this. I [analyzed] 55 [such] handouts, and I was looking for how they cover the alternative of not circumcising, because this has just been totally ignored, except for that little bit in the previous study I told you about. So, what I did was I read these handouts and I found within them 12 different topic areas that relate to not circumcising:
How [did] they talk about the anatomy, the functions, the care, [and] the development of the intact penis?
How [did] they talk about intact penile hygiene in terms of how [that is] framed—we'll talk about framing.
What kind of counter-information was given when a claim for a medical or a social justification was given for circumcision—[for example], they say “It prevents penile cancer”, but do they mention that it's really really rare, or do they just leave it at “It prevents penile cancer”?
Did they talk about the ethics of neonatal circumcision?
Did they talk about the fact that circumcision is not practiced in most societies?
What kind of terms did they use to refer to the normal penis? Did they use the word “uncircumcised”, or did they talk a “normal” penis, a “natural” penis, an “intact” penis?
So, I looked at all of these 12 [categories for each handout], and I scored [a handout such that] if [it] did a decent job in each [category], [then it] got one point [for that category, and thus a maximum of 12 points overall]. So, here's how it turned out. I got a ton of data out of this study; it was really interesting, but I can only show you a couple of things. This is the general overall adequacy score for how they [talked] about not circumcising. You can look along the bottom, and you'll see the [bias of various] groups:
There was one pro-circumcision handout [that] got a score of 1.5 out of 12.
[There were 6] North American medical organizations [that] had an average of 3.83 [categories] that they talked about out of the possible 12.
The North American “miscellaneous/other” [health care] sources [got score that was] a little bit higher.
Then you get to Australia and New Zealand. I made my cut off [for determining adequate information a score of] 6 out of 12. This is where we get into that [level of information adequacy]; they had an average of 6.7 [out of 12] for their handouts, talking about not circumcising.
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The anti-circumcision handouts ended up with a score of 10.3 out of 12. You look at this, and you say: “Well, that's got to be biased! I mean, that's just so high there!” But, what the anti-circumcision handouts were doing was giving information about the alternative of not circumcising, and they were a doing a very good, thorough job of it.
What's more concerning is what's not being talked about on the other end of the spectrum of the North American sources; they were only talking about 4 out of a possible 12 relevant things that could be talked about, so parents who are only relying on these kinds of sources are not really giving fully informed consent for circumcision at least as far as knowledge about what [foreskin is], what [needs to be known] about not circumcising.
Another feature that I looked at in my handouts study was how the alternative of not circumcising was framed. This is a whole interesting topic in psychology and communication studies. Framing is a concept which refers to the fact that how a story is told affects how that information is perceived. So, there's the risk [that] framing in health communication [alters] a person's cognitive understanding; it can have detrimental effects, in other words, on a patient's understanding and on patient autonomy. It can be used for benefit as well, but in this case, there was a problem.
Now, John [Geisheker] gave a really good example of [framing]: Relative risk and absolute risk: “Circumcision reduces your child's risk of X, Y, and Z by 60%.” Well, that sounds like a lot! That's the relative risk, but if the likelihood of ever actually getting that disease is really [very] small, [then], well, the absolute risk reduction is not going to make a whole lot of difference. [In this case, framing] is where we get relative risk information only, which is really mostly what shows up in the information parents are given; it unrealistically exaggerates the impression of benefit from circumcision.
Now, in my study, the second one down, I found that when they talked about hygiene of the intact penis, it was much more often discussed in the North American handouts using negatively framed messages instead of positive ones, and what I mean by that is [they gave] the impression that if you don't clean your boy's “uncircumcised” penis “properly”, there could be “dire” consequences—[he] could get this or that disease; that's a negatively framed way of talking about hygiene, as opposed to just saying: “Well, it's very easy to take care of the intact penis.” That's a positively framed message, and there was much more of the negative [statements] in the North American [handouts].
Finally: Omission of relevant information. Framing is defined as much by what's left out as by what [is included]. That's what we saw here; this is left out on that side. So, what happens is that ethically and practically, parents are in a really big problem if you leave out relevant information, because how can you weigh your alternatives if you're only told about one option? How can you take into consideration something that you don't even know exists? So, [omission] constitutes informational manipulation, and we talked about the elements of valid informed consent. [Manipulation violates the voluntariness standard, and when it's done with information, it violates the informed standard], so it's violating 2 principles of the validity of informed consent when you do any of these things.
Now, I'm just going to finish with informed consent with one other slide here, and I have a caveat here as well: Even if parents were given complete and unmanipulated information, proper informed consent does not make circumcision of children ethical; if non-therapeutic circumcision of children shouldn't be done in the first place, and if parents are [indeed] not the ones who ought to be making that decision, then the informed consent [by] parents is a moot situation (although, of course, an adult [choosing circumcision] for himself should have this proper informed consent).
But, here's the thing: The reality of it is that parents are being given the choice whether to cut their [children's] genitals, and [in addition to that erroneous authority], they're not being given anywhere near enough adequate information on which to make that decision. So, [working] in this hospital setting where I see this going on every day, I [have come to] believe that insisting on higher standards for informed consent is part of what we need to do to shift the practice in our country; [it would give] parents the opportunity to make a truly informed decision for that person who is depending on them, and it [would] also [force] health professionals to become more informed about things like the functions of the foreskin [and] the value—and normalcy—of leaving boys whole, things [about which] they're currently not very well educated, and this in turn [could] lead to more of them maybe reconsidering their position on being involved with circumcision.
Impact on Health Professionals
So, the last little segment here has to do with health professionals and how circumcision ethically impacts them. [Consider] this quote:
I did not become a nurse to hurt babies. In 1992, I gave notice to my employers that I would no longer be an accomplice in the atrocity that is infant circumcision…
So, she refused to participate, and this is the position I've taken at my work; I've been threatened with termination twice because of that. [She continues]:
"… I have reclaimed my tattered soul and begun the process of becoming whole again."
A number of medical organizations acknowledge the health professional's right not to participate in circumcisions. Conscientious objection is widely acknowledged for health professionals; [they have a right] not [to] participate in things [to which] they have a cultural or religious or ethical objection.
There are nurses and doctors all across the country who have said: “I'm not going to be part of this; I'm not going to be involved with circumcisions”, but there are [also] a lot of barriers to conscientious objection. I think the primary one is the lack of education of health professionals; they simply don't have enough information about the foreskin [or] about the ethics involved [with circumcision] to lead them to be able to form any kind of ethical stance.
It took me a while to get to [this] point. I mean, I didn't circumcise my sons, but I didn't know that much about it; it was just a gut-level [feeling], and as I worked in the hospital environment, I still thought: “Well, it's the parent's decision; I want to be a team player.” So, I would clean up and I would set up and that sort of thing, and then when I really started learning about it about 10 years ago—there was no Internet when I had my kids—I finally started digging into what's out there, and I was realizing not only do I dislike this [practice], [but] this is really wrong, and [I began thinking]: “I'm not going to have anything to do with it!” [It] takes time for someone to become educated enough to take that stance and just say “No way!” So, we need to change medical education.
The other is the problem with the lack of ethical leadership from the AAP, and you saw the way they wishy-washed about [circumcision being] the parent's choice, and so forth. They're putting the message out to practitioners out there that this is an OK thing to do to children, and [that doctors] are there to do whatever the parents want, and so they do that! They're not getting any other message from [the AAP], although we did see that [alternative message] from the other medical organizations outside of the U.S.
There's also a host of problems at the institutional level:
- Threats
- Stonewalling
- Harassment
This goes on all the time, and I think there [are] personal concerns of some doctors, but basically everybody is afraid of sticking their necks out; I've talked to the ethics committee head at my hospital, and he [has responded by saying something like]: “Oh, this is very interesting”, but [it's clear that] he's just going to sort of go along with what [everybody else is doing]. Nobody wants to rock the boat.
Now, there are a bunch of other ethical issues that I don't have time to talk about, [which] are more specific, but [which] I just kind of want to [let you know exist]:
Commercial use of amputated foreskin tissues.
Where religious rights and [a] child's rights interface with each other.
So, please continue to educate yourself and go out and start to put these pieces together. It's important that anybody [who] is educated in this area see that this is the bottom line of what it's all about, and to be able to explain to others why circumcision is not ethically valid.
So, in closing, I want to indicate a couple of avenues [through which] we have the opportunity to move forward, [in order] to have a more ethical future [regarding] circumcision:
First is the education of health professionals on the foreskin and the ethics of circumcision, which is currently seriously deficient; [when] more health professionals are educated enough to understand that this has no place in modern ethical medical practice, it will end.
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Second is culture. Cultural blindness can color our perception of ethics and human rights; I pointed that out a couple of times. This is a [picture of a] statue from a statue park in Norway (it's one of the many countries that have never practiced circumcision); [here] the foreskin is seen as familiar—it's seen as normal. In that country, there are medical organizations and governmental children's advocates who are actively working to protect all children—both males and female—from non-consenting genital cutting.
Compare that to our complacent attitude here in the U.S. But, our culture is changing: The rates are going down, and hopefully we're reaching a tipping point; [choosing to circumcise is] no longer the overwhelming norm, and it's conferences like this that are going to lead to a more critical mass of people who really understand the foreskin and the ethical issues involved.
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Finally, I would say gender is another area where we need to move forward. As we've seen, there's a big disconnect [between] the attitudes that we have towards female and male genital cutting. You have to argue from the parallels of the ethics of those 2. It's part of the necessary ethical discourse to move us forward; if you can see those parallels, then another chink has been made in the wall.
So, anybody here who is concerned with gender [or] concerned with feminist issues or concerned with female cutting or equal rights or any of those things, it's very important that you understand that male genital cutting is an issue that all humans beings have to deal with, and we all need to work together to protect all children.
So, finally, I'd like to end with a quote from the circumcision position statement of the College of Physicians and Surgeons of British Columbia—and that's another one that has done a really thorough job of discussing the ethics of neonatal circumcision:
Ethics points us to corrective vision, i.e. to question practices that have become routine, or which we take for granted.
So, I would say it's time for our culture to [stop] being complacent about circumcision. It's time for us to question it. It's time for us to think ethically about it. It's time to go out and be part of that ethical correction that we need.
Thank you very much.
Discussion
Woman #1
I'm wondering about the fact that pediatricians, who are not trained surgeons, are practicing circumcisors. I mean—
Gillian Longley
Well, doctors are taught to do procedures. I mean, you can do different kinds of minor procedures; it's just a matter of whether you've been taught or not. So, pediatricians and family practice doctors do it.
Obstetricians have done most of the circumcisions in the United States, and they are trained surgeons, but they are trained to be the professionals that take care of women, and not children, so that's the odd thing I think. Yeah. Pediatricians and family [practitioners] are the only ones who do it in my hospital, but some places, it's only the obstetricians [who] do it.
That's an interesting thing. I did recently talk to a family practice doctor who saw [Eliyahu Ungar-Sargon's] film and said: “I think I've done my last circumcision.” She said that for family practice, they're like the lowest man on the totem poll; they don't get to do [any interesting procedures], [so] everybody looks down on them, and this is one little procedure that they can do! “I can get good at this! I can say I can do procedures!”, and there's a certain [appeal] about that. Now she sees through it, but that was one of the things that was motivating her to do them. So…
John Geisheker
Gillian, that was excellent! Thank you very much! I enjoyed it thoroughly.
I have a question for you, and it was certainly beyond the scope of your time frame to go into this: [There] is the autonomy of the individual, but it also could be argued that there's the autonomy of the family and the group in which the family finds itself. So, of course, there [are] going to be groups who make an argument that “If you take away this procedure on this child, you're taking away the bond we have with that child—the bond that child has with our tribe.”
So, one of the escape valves in your bioethical analysis here is of course alleging that if you're an Orthodox Jew or if you're an African Animist or if you're a Somali Muslim, that somehow that [identification] gives you a certain tribal need to do your historical procedures on your children, lest you reject that child as not an adequate member of the family or an adequate member of the tribe.
You see that as a problem, I'm guessing?
Gillian Longley
Well, let's see. I don't have a Ph.D in bioethics, so I may not do this like a perfect answer, but I caught some things [to which] I think I can respond. First of all, [the] human rights documents from the United Nations [do] specify all these rights that human beings have, and [they include] religion [and rights] to your traditional practices, but at the end it says [something like]: “Nothing in this document should be [construed as giving] you the right to overrule somebody else's right.”
The very first [right] (at the very top) of the Declaration of Human Rights is security of person. So, you know, I don't think the affiliative argument is necessarily going to be the dominant argument; there's certainly this other way of looking at that: Causing harm to the physical integrity of the child; sorry, [but] your religion does not [justify] that.
I know this came up in [Eliyahu's] film, and I don't know how you answered it in the film. Do you just want to say something quick, because I know it came up [in the film] when [you talked] to your dad about being part of the tribe or not.
Eliyahu Ungar-Sargon
Yeah, [the] particular context [is that] my father brought up [the notion of] being part of a community, and the sociological rationale and the shaming and the shunning that would go on to a member who wasn't circumcised, and [then directly from that scene], I [naughtily transition] to an analytic philosopher, Raja Halwani, [to whom] I put the question, and his argument was that the question of shame is whether the shame is merited, and the mere fact that someone feels shame about not being circumcised or not being [like] everyone else isn't enough to recommend the practice.
But, more to the point, I constantly try to blur the line; I resist this distinction between a person who's circumcising for Orthodox faith, [and] a Somali family who wants to circumcise [a] daughter for cultural/religious reasons, and Americans doing it in hospitals. I'm constantly trying to blur [these], because I think at root we're all human beings, and so the ethical problems are actually quite similar.
Marilyn Milos
[NOTE: Marilyn Milos previously threatened legal action for transcribing her words. Therefore, they have not been reproduced here.]
Eliyahu Ungar-Sargon
I should add just a point: I think there is a point of confusion that happens over this, because you'll hear people who are opposed to circumcision use phrases like: “You can't do it for no good reason”—I've used phrases like that myself: “You can't for no good reason!”
Of course, what we mean is that [you can't do it] for a reason that doesn't trump all of the problems that we're talking about—the suggestion isn't that there aren't significant cultural reasons for the practices or that [these practices] haven't been attributed cultural significance; that's not the argument. I think everyone accepts that these are deeply embedded cultural practices, whether you're American or Jewish or African, and cultural practices of this nature have a tendency to collect very important rationales as they perpetuate themselves.
Yes, they are important cultural practices, but that doesn't override all of the problems, and I think that's really the crux to recognize and articulate:
We recognize that these are central cultural practices, that they have important cultural value, but that value doesn't override the human rights violations that we're talking about.
Woman #2
Also, Gillian, this is a medical ethics discussion, and our nursing licenses [and] a doctor's medical license [don't] require [the holders] to [be] cultural [agents] of a ritual; there's nothing in there that says we have to do any such thing, and in fact, we shouldn't do any such thing if it violates the individual's right.
So, they need to take it down the road a piece if they think it's so important to their collective autonomy—like you were talking about. That still doesn't eclipse our licenses and our nursing ethics to protect our vulnerable patients or a doctor to do no harm; [the cultural argument] doesn't eclipse that.
Gillian Longley
Yeah, and the United Nations does make a point about female genital cutting: “Yes, it's a cultural practice, and we need to respect cultural practices”, but they'll draw a line and say: “This is harmful to the child, so we don't recommend that.” It's the same thing; we've got this gap where we'll say it's not OK to do to girls even though [there are] cultural reasons to do it, but it is OK to do to boys [for cultural reasons]. There's the disconnect again.
Woman #3
I apologize because I came in late, so please excuse me if my question is something that's already been dealt with or covered, but I'm wondering if anyone in the room might be able to offer me a little guidance on this.
Often when I sit with families who are considering circumcising their sons in my work, I will touch on the ethical conversation as much as they're willing to let me, and what I come up against is often with the men in the room who [were] circumcised. So, you're in this ethical kind of viewpoint [such] that we're then [considering how] what was done to them was unethical; [there's] obviously the implication that those [who] did this to you are unethical and therefore it's a rejection, or somehow these people have done something awful to you.
[When] we hit that point in the conversation often, things kind of go silent, and there's this back away, because it's such a painful thing, so when I'm sitting here listening to the sort of intellectualization of the ethics of this—and it all makes sense to me, but [then] that emotional component comes in; [I'm wondering if you], either as educators or as people in the health profession, [have] any insight. Where do you go on that next level? Do you know what I mean?Gillian Longley
You've gone [to] the realm of giving them awareness that their child is this person separate from them who may want to have a say about what happens to his body.
I think when you talk about ethics, people say: “Who are you to tell me what's right and wrong!?” You know? But, several medical organizations do say we ought to be talking about the ethics of this with our clients, whether it's comfortable for them or not.
[However], when you're getting into the emotional defensiveness piece [of the discussion], you've gone into another realm. I mean, it's going to come up whether you're talking about ethics or not. It's going to come up if you teach them what the sexual functions of the foreskin are—it's going to come up! That's the sad thing: When you educate people about this [issue], there's going to be trauma coming up for anybody!
For a person who's had it done to [him].
For someone who has done it to somebody else.
[For] a person who participated in it as a health professional and [who now] knows how wrong it is.
So, Marilyn, do you have a thought that you'd like to add to dads who feel that way.
Marilyn Milos
[NOTE: Marilyn Milos previously threatened legal action for transcribing her words. Therefore, they have not been reproduced here.]
Eliyahu Ungar-Sargon
I just want to add quickly: I think art is really important. One of the things about art that it can do that presentation of facts or ethical arguments even can't do is that it can appeal directly to emotion.
Woman #1
One of the most important parts of my job as lactation consultant is counseling. Counseling is the most important, because you have to find out where they're at, and where they're thinking before you can give them information. You can't just overwhelm them with information. So, when you start seeing that body language of an emotional wall going up, you need to ask questions and listen a lot more, and find out what's really going on with them before you can proceed with more information.
Gillian Longley
Would you literally say: “I see [you're troubled]. What's going on with you right now?” I have these questions, too. I'm a nurse; I talk to patients, and sometimes it works and sometimes it doesn't. I think we all need to share what's worked.
Woman #1
“How do you feel about that?” or “What are your thoughts on that?” Get them to start talking. Maybe ask an open-ended question that gets them to start talking more: “What do you think about circumcision in the United States?” Something open-ended.
Gillian Longley
One of the things I've come up with—and I tried for about 10 years to figure out the best way to talk to parents—is to literally just ask the question:
“Well, have you considered not circumcising?”
That's not a threatening question, but [it gives them] permission to think about not circumcising, and maybe they haven't even thought about it, which probably a lot of them haven't, and if they have, then they'll say “Yeah, well, we just thought it would be easier to take care of if we had it done”, and then you have something to educate them about rather than just going in there and beating them with information.
Woman #1
In my certain practice [as a lactation consultant], a lot of times, I don't meet [until after the birth]. Once in a while, I meet [the parents] beforehand, and I'll talk about it, but most of the time, I meet them afterhand, and then I'll talk about scheduling the next appointment, and they go:
“Oh, well, I can't do that because he's being circumcised.”
So, I'll kind of [tell] them that's not medically necessary, and kind of wait to see how open they are to discussing it, and then suggest:
"How about if we just put it on hold for a little while, because he doesn't have the hang of breast feeding yet, and this is going to really interfere with that."
Then just give them more information on the next appointment and so forth.
Woman #3
Yeah.
Marilyn Milos
[NOTE: Marilyn Milos previously threatened legal action for transcribing her words. Therefore, they have not been reproduced here.]
John Geisheker
I hope this doesn't sound like hectoring, but I'd like to remind the medical professionals in the audience that actually when you're counseling parents about circumcision, you already have a patient: The unborn child. That is your only patient.
You're counseling the parents; in other words, you're chatting with them, but they're not the patient—they're not the person whose being operated on, so fundamental bioethics applies. It seems to me at that point, you need to be an aggressive advocate for your client, the patient.
You can cajole and jolly up the parents all you like and talk to them about these other issues—and I think you need to—but at a certain point, you have to realize that's sort of window dressing for the fundamental bioethics.
Marilyn Milos
[NOTE: Marilyn Milos previously threatened legal action for transcribing her words. Therefore, they have not been reproduced here.]
John Geisheker
By telling them!
Marilyn Milos
[NOTE: Marilyn Milos previously threatened legal action for transcribing her words. Therefore, they have not been reproduced here.]
John Geisheker
It is interesting that there have been studies done showing that you could list all of the [complications] (there [are] about 100 problems with circumcision; Dr. Bob Van Howe has a 20-page informed consent [document]), but most doctors say parents come in with their mind already made up, and they're made up around cultural issues—they're not made up around medical issues; you can just endlessly show them pictures of mangled penises, [but] they'll still ask for circumcision if they're that set on it.
Gillian Longley
Yeah, well, the process is really ass-backwards, because most [parents] have already made their decision based on no information. Then, they show up at the hospital, and they're asked before any [medical] problem presents itself whether they want a surgical procedure done [to their child's penis], and then after they're already committed in their heads and the doctor has already given the stamp of approval by [just] asking the question, then 3 lines of minor complications and platitudes [are stated by the doctor for the purposes of] “informed” consent, and that's it! The whole thing is a travesty!
Travis Wisdom
I was going to say, [Gillian], you talked about something in your presentation—first, before I go to that: I just applied for a masters degree in medical ethics and law, and it was one of the 3 that applied for, and [yet] I thought I didn't really want to do [that subject], but your presentation really kind of solidified [in my mind] that [it]'s actually something that I'd like to continue; so, that was good.
In addition to that, you talked about the commercial use of the amputated foreskin tissue. Could you speak about that a little bit?
Gillian Longley
Yeah, I don't have a lot of detail, but I know that foreskin cells are used in a number of different products for:
- Research purposes
- Growing skin grafts
- Cosmetics
I'm not going to make any claims about people making millions of dollars off purloined foreskins; I don't know whose collecting them or how they've been collected or whether one foreskin was collected 50 years ago and has been growing cells—I don't know all of that—but I know that they are used in these commercial products.
[There] are specific bioethical restrictions on what you can do with tissue that has been removed from a human being; the person is supposed to give consent for its use, and there is supposed to be some kind of arrangement by which that person can be compensated for the use of their body tissues, and both of those are in United Nations documents on bioethics. So, that's the most I can tell you, unless somebody has more specific information.
Marilyn Milos
[NOTE: Marilyn Milos previously threatened legal action for transcribing her words. Therefore, they have not been reproduced here.]
Gillian Longley
I don't know how widespread that is. It doesn't occur at my hospital at all, so I don't really know. I think maybe there needs to be an exposé done on that, but I don't think we have specifics.
Woman #4
I'm really glad that you asked that question, Travis, because that was what I was going to ask in regards to this dialog about ethics: What is the literal cost of doing this? Marilyn had mentioned it's like a million or billion dollar industry. How much does one circumcision cost for a family?
Gillian Longley
Probably in the newborn period, it's in the several-hundred dollar range. I think if it's done outpatient or older, it's going to cost more. I've heard between $100 and $400 for a newborn.
Woman #5
I also read that any practice that incorporates circumcision increases [its] profits by $114 thousand dollars a year.
Gillian Longley
I'm hesitant to attribute the continuation of circumcision to just the financial motivations, but the fact is that in the countries that used to circumcise and now no longer do, a big part of that [transition] was that the government stopped paying for it; so, [because] there wasn't a money stream for it, [parents had to pay] out of pocket, [so they just didn't do it].
[We] don't have that system here in the United States; private insurance, for the most part, pays for it. Most states pay for it with Medicaid, although more and more have stopped paying for it because of budget problems and because it's not medically necessary and it goes against federal mandates, but I think anytime there is a money flow, that's going to be a factor.
Woman #1
Now, here in Las Vegas, circumcisions are not traditionally done in the hospital, which I think helps a lot; it gives the parents a chance to bond with their baby. I don't know why that is—and I don't know if that's changed (because we have so much big growth so fast that we have a lot of new hospitals), but as far as I know, it's still not being [done in hospitals], and I don't know if that's statewide or not. I don't know if anybody knows if it's like that elsewhere, and I don't know the reason why; [it] would be helpful if you could find out the reason why it's not done here to see if we could use that for other states.
Gillian Longley
Well, I do know that the Medicaid states are all over the country, but everything west of the rocky mountains except for New Mexico does not pay for circumcision with Medicaid, so all the [circumcision] rates on the west coast [are] the lowest in the country; California was the first one [to drop Medicaid support] in 1982, so it's been a long time for not paying for circumcisions, and it has become the norm [on the west coast] not to circumcise.
[The concern] is [that] the [rate] numbers [have] to do with hospital discharge data, so that data may look very low, but how [many circumcisions are] taking place in doctors offices afterwards? I don't think anybody really knows. Just like anything else with medical practices, it's going to vary from region to region.
Marilyn Milos
[NOTE: Marilyn Milos previously threatened legal action for transcribing her words. Therefore, they have not been reproduced here.]
Gillian Longley
For hospital discharge data—
Marilyn Milos
[NOTE: Marilyn Milos previously threatened legal action for transcribing her words. Therefore, they have not been reproduced here.]
Man
Let's hope not!
John Geisheker
I have to tell you: I don't think that the move from hospital circumcisions to outpatient [circumcisions] is a particularly good one. For one thing, we have no notion of what the morbidity is—none whatsoever; there's not a single state in the U.S. that requires outpatient circumcision reporting, and no doctor is required to report a botch, and I talk to pediatricians all the time who say: “I see 2 or 3 botches a week. But, you know, what can I do? I can't tell the son. I can't tell the family. I'm sort of stuck.”
Woman #1
It also seems unlikely to me that the parents are going to go back to the person who botched the circumcision. So, [the doctors are] often not going to know that they botched the circumcision.
Gillian Longley
John, [you mentioned that there's] no way to track what's going on with the outpatient [circumcisions], [but] there's no way to track what goes on in the inpatient either, because nobody's keeping statistics; there's no national system for tracking adverse events after circumcisions, so we don't really know how many babies die or need antibiotics or need blood transfusions—we don't know.
Eliyahu Ungar-Sargon
I was just going to add that we have some very recent data from the American Academy of Pediatrics that the rate of revision circumcision seems to be climbing, and no one has been able to give an adequate account as to why that is [the case]—revision circumcision being that parents have the baby circumcised in the hospital, and then for some reason, they need to go in for further surgery along those lines.
Woman #2
Dr. Marty Koyle, who's a pediatric urologist at Children's Hospital in Denver, he's a leader in repair of [circumcision] botches; he makes his entire living repairing botches.
Most of the children he sees are under age 2, and he said that there's been a push in medical schools to make the circumcisions loose, and so then they have adhesions, because they take very little foreskin, and they leave it and it re-adheres [to the head of the penis], so then they go in for a revision or a second cut.
[Also], I worked urology surgery for 4.5 years, and one of the urologists [with whom] I worked, his entire living was 3.5 days of botch repairs on adults, and a day and a half of office [work], and that's one urologist in one city, and he made an entire, incredible living on that.
John Geisheker
By the way, repairing botches is easy: You simply just take off more tissue; you [cut] off [the] guy's scar tissue, and create new scar tissue, and make the penile sheath even shorter [in the process]. It's an easy surgery, and it's even more destructive.
Gillian Longley
Any other questions?
If you're a health professional or doula or midwife or whatever, I do have some handouts on informed consent that I developed relating to circumcision, and I'd be happy to give you one. I know there [are] some excellent handouts in your packet from NOCIRC. Colarado NOCIRC has developed its own parent handouts, so if you want to have that to use with your clients as well, I have copies of that.
Thank you very much.
Eliyahu Ungar-Sargon
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You have a splendid blog and I salute you for your work to end the insanity of circumcision. I should very much like to make contact. You can e-mail me at norm-uk.org just put patrick@ in front. Cheers.
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