Put an End to Circumcision

Malama I Na Keiki, Ending Non-therapeutic Infant Circumcision Through Education

• Download a PDF version of this Medical Abstract Here

 

"The object of our discussion is not that your words will gain victory over mine, or that mine will triumph over yours, but that together, we may discover the perfect truth.”    Socrates

 

 

psychological and physical pain to discourage the practice.

 

Subsequently there have been a number of rationales provided for this procedure, including prevention of sexually transmitted infections, urinary tract infections and, most recently, HIV transmission. These rationales for the procedure have either limited support from flawed research or often contradictory evidence. The surgical removal of healthy tissue from a nonconsenting infant raises ethical and human rights concerns. The foreskin is of importance to male genital health and function throughout the lifespan. The loss of these functions, the pain and potential complications of the procedure, in addition to the above concerns, make it necessary for us to revaluate and discontinue this procedure.

 

Our goal as healthcare providers is to optimize the psychological, spiritual and physical health of all those in our care. While the negative physiological effects of circumcision have been documented, it’s harm to the psychological and spiritual health of the previously intact baby is immeasurable.  These concerns often are not adequately discussed when educating parents about circumcision. Circumcision also profoundly and negatively impacts the psychological health of providers, immediate family and society. Circumcision negatively effects breastfeeding and bonding.  Many arguments have been presented to support this traumatic practice. However, there is a preponderance of evidence that supports preservation of genital integrity for both male and female infants.

 

Circumcision is a Traumatic Event

Until recently, the myth was promulgated that infants’ nervous systems were not adequately developed to feel the pain of circumcision. The truth, with regard to the perception of pain, is that the nervous system of an infant is fully developed by the third trimester.

 

Until recently, the myth was promulgated that infants’ nervous systems were not adequately developed to feel the pain of circumcision. The truth, with regard to the perception of pain, is that the nervous system of an infant is fully developed by the third trimester.1

 

Newborn responses to pain, in fact, are greater than those in adult subjects.2

 

Fifty percent increases in heart rate and three- to four-fold increases in cortisol levels have been documented in response to circumcision.3

 

Many parents and practioneers point to the reduction of crying when a pacifier is used during circumcision, believing, with less crying, pain and stress are reduced. The truth is that, although babies do cry less with a pacifier, their stress response and cortisol production are unchanged.4

 

For some time, there has been a strong trend to return to non-traumatic births and nurturance of our newborns and infants. Women are encouraged to eat well and reduce stress for the health of their babies. Parents talk to their babies, sing and read to their children before they have even entered this world. Yet, shortly after birth, many baby boys are met with a scalpel. The Midwifery Model of Care in Holland has become an international birth model because of the low maternal and infant mortality and morbidity rates. The standard of care in Holland is optimal outcome with minimal intervention.5

 

Circumcision stands in stark contrast to this concept of harm reduction, nurturance, optimal outcome and minimal intervention. Circumcision meets the definition of a traumatic event and a baby can go into shock in response to the procedure. The absence of crying can be part of the shock response and is not an indication that there is no pain.  Bodily signs show that severe pain is always present.3

 

More recently, medical doctors have admitted that infants do feel pain, and local anesthesia is often used now prior to circumcision. While this reduces certain responses to pain during the procedure, it does not eliminate them, and it introduces another painful procedure, the injection of the anesthesia. The effects of the local anesthesia wear off in a matter of hours.6 The pain experienced in the subsequent hours, days, and weeks is not affected by this anesthesia. This pain interferes with mother/infant bonding and breastfeeding.

 

The very act of breastfeeding and maternal contact has been shown to attenuate the physiological responses to stress. According to Dr. McGaff at North Hawai’i Community Hospital, “In the last five years, purely through prenatal education, we have been able to drastically lower the circumcision rate in our birthing unit at North Hawai’i Community Hospital on the Big Island.

 

There are several noticeable improvements. Our staff is calmer, breastfeeding and bonding seem to proceed more easily, and the baby boy remains protected, respected and whole.  Since circumcision interferes with bonding and breastfeeding, and these naturally and wonderfully attenuate the stress response, it quickly becomes clear that this single, medically unnecessary, mutilating act begins a cascade of events that leads to a downward spiral in multiple aspects of the health of the child, mother and family. During and after circumcision the child is in severe pain. Due to this pain, the baby often has more trouble nursing.  Failure to successfully nurse prevents the assimilation of passive immunity from antibodies in the colostrum and breastmilk. This passive immunity results in significant disease prevention in the first six months of life. The pain of circumcision also results in elevated cortisol levels, which further suppresses the newborn’s immune response. 7,8

 

The distress of the newborn from the traumatic experience of circumcision has a deep impact on the parents’ ability to successfully nurture and care for their baby. The inability to nurse is not only due to the impact on the newborn, it also is related to the stress the mother feels when caring for her distressed baby, unlike the comparatively peaceful experience of nursing a happy, untraumatized baby. This series of events leave a baby more vulnerable to infection (which can result in otherwise unnecessary spinal taps) and the mother more susceptible to postpartum depression. 

 

“Circumcision causes pain, trauma and a permanent loss of protective and erogenous tissue. Removing normal, healthy, functioning tissue violates the United Nations Declaration of Human Rights (Article 5) and the United Nations Declaration on the Rights of the Child(Article 13),” Dr. Leo Sorger.(9) There are many other articles in the United Nations Declaration of Human Rights that relate to circumcision.  They include, but are not limited to, abolishing traditional practices that are harmful to the health of the child, protecting children from all forms of violence, injury or abuse, protecting children from sexual abuse, and not allowing children to be subjected to torture or cruel inhuman treatment.(9)

 

The Myths and Risks of Circumcision

Confronting the myths of circumcision and healing the pain it has inflicted on our society is crucial. Early medical justifications for circumcision, in fact, were hardly medical or scientific at all, but were based on conservative, punitive religious judgments about sexuality and masturbation. In 1860, The Lancet reported that male circumcision was a procedure needed to break the habit of masturbation. Dr. Athol Johnson stated that the procedure needed to cause much local suffering so that the “practice” would not continue.10 Dr. Harvey Kellogg also talked about the benefit of circumcision as having ……”a salutary effect upon the mind, especially if it be connected to the idea of punishment.”10 What followed for the next century-and-a-half has been one justification after the other, each of which has failed to unequivocally stand up to objective evaluation.

 

At the same time, the complication rates for infant circumcision have never been adequately researched.(11) Complications from circumcision have been estimated to range from 0.6% to 55% in different studies.12

 

Worldwide, routine infant circumcision is the exception, not the rule, and is rarely practiced in Europe, Central and South America and Asia.11

 

Complications due to circumcision are extensive, underreported for reasons of litigation and include surgical mistakes that can include damage (beyond the damage of circumcision itself) to or loss of the penis, hemorrhage, infection (as frequently as in 10% of all circumcisions), and death.12

 

One of the authors, Clare Loprinzi, has witnessed a healthy baby boy dying as a result of bleeding from circumcision. There is no central registry of circumcision deaths. In the 1940’s when circumcision was common in England, there were 16 deaths-a-year reported. (9)

 

There is an increasing incidence of virulent antibiotic resistant microbial strains such as Methicillin-Resistant Staphylococcus Aureas (MRSA). The unnecessary infliction of an open wound, in an area constantly exposed to and possibly colonized by potentially pathogenic microbes, in a newborn baby that has an underdeveloped immune system, is not rational. Circumcised boys have a twelve-times greater risk of community acquired-MRSA.13

 

Dr. Sydney Gellis, at the Department of Pediatrics, New England Medical Center Hospital, states that physicians should be more vociferous than ever to stop circumcision because the circumcised infant is at greater risk than ever before.14

 

He adds that it is an uncontestable fact that there are more deaths from complications of circumcision than that of cancer of the penis (more than 200 deaths per year).9,15

 

Circumcision has been promoted to prevent urinary tract infections (UTIs). The American Academy of Pediatrics (AAP) Task Force on Circumcision, in their 1999 evidence-based statement, reported serious methodological flaws in all existing studies, and declined to recommend circumcision to reduce UTI’s.15 The AAP reported that previous studies, showing that circumcision reduces UTI’s, were retrospective, may have had methodological flaws, and influenced by selection bias. The studies about intact males having a greater rate of UTI’s failed to control for confounding factors, which included maternal infection, perinatal anoxia, high or low birthrate, prematurity of birth, rooming-in, method of urine sample collection, type of hygienic care and breastfeeding. UTI’s are easily treated and even circumcision advocates only estimate an incidence of 1% in intact infants, so it is unreasonable to subject the remaining babies to the trauma, pain, risks, and loss of this procedure to prevent the occasional UTI.

 

Phimosis (a nonretractable foreskin) is another reason given for circumcision. There is a reason why the foreskin is adherent to the glans at birth. It is protecting the glans from exposure and irritation, the urinary tract from contamination, and the nonretractability makes cleaning under the foreskin unnecessary. At rates that vary for each child, the foreskin will become retractable between infancy and 18-25 years of age. Clearly, phimosis cannot be diagnosed in infancy or early childhood. That would be premature and poor practice.

 

Education for healthcare providers and parents about not retracting the adhered foreskin is important because doing so results in unnecessary injury and possible problems with infection and adhesions. Premature retraction is based on antiquated information that is still being promulgated. Perhaps more importantly, the incomplete amputation of foreskin during circumcision can result in post-circumcision, iatrogenic phimosis. Circumcision can cause a condition it is intended to treat or prevent. There are gentle, alternative ways to get the foreskin to retract in the rare case of a young man for whom this is a concern.(12,8)

 

The notion that circumcision prevents sexually transmitted infections (STIs) predates any studies conducted on the subject. Studies that have been conducted do not verify the notion. We are not aware of a meta-analysis of the studies that have looked into this subject. Looked at individually, these studies show little difference between circumcised and intact men. Some studies show small increases for different STI’s in each group, another showed no statistically significant difference.15-19 

 

It is clear to all concerned health-care providers, including the 1999 AAP Task Force on Circumcision, that  behavioral factors are far more important than circumcision status in affecting STI acquisition. This fact should be remembered when considering circumcision status and HIV transmission.

 

The Latest Fallacy, HIV Prevention

The latest claim of pro-circumcision advocates is that circumcision will help prevent HIV. When one looks closely at the studies used to support this claim, it is clear that the men who carried out the RCTs have a previous history of promoting circumcision. It is also interesting to note that many researchers have suffered circumcision as infants and are likely to defend their beliefs to support circumcision.20 It takes a lot of healing for a man to realize what happened to him as an infant and the sexual losses that occurred because of it.  Ideally, researchers from circumcising cultures, themselves circumcised, who have advocated for circumcision as a disease-prevention modality, would recuse themselves from designing and evaluating such studies.
 
There have been several thorough critical evaluations of these studies and they suffer from several methodological flaws, in execution and evaluation.21

 

These flaws include, early termination of all three studies, lack of long-term follow-up (and eliminating of the possibility of long-term follow up by circumcising control-group participants after early study termination), failure to account for non-sexual HIV transmission, failure to assess sexual exposure rates (which would presumably be reduced in the circumcised group due to time necessary to heal from the surgery).21

 

There are many reasons that this approach is a bad idea as a disease-prevention modality. They include, but are not limited to, circumcision and medical procedures being leading causes of HIV spread in Africa, increased HIV transmission to sexual partners of recently circumcised HIV positive men, and diversion of limited resources from proven preventative methods, such as universal condom use.

 

Circumcision status does not affect male-to-female or male-to-male transmission rates. A false sense of security could undermine proven effective preventative measures. As Dr. Dean Edell has stated, “ The foreskin is one of several possible entrance points for the AIDS virus to infect the body, but that does not mean that you should cut the entrance off. It means that you should protect the entrance, either by using condoms or by practicing safe sex.”  Dr. Haanah Kibuuka of the Makerere University Walter Reed Project in Uganda has made the following recommendation to his countrymen, "Do not expose yourself to danger in the mistaken belief that since you are circumcised, you will not catch HIV."

 

In Thailand, it has been shown that behavior change, such as abstinence before marriage and fidelity after marriage, provision of condoms, treatment of other sexually transmitted infections, treatment of genital ulcer disease, control of malaria, and provision of safe healthcare, produces beneficial results.(16)

 

Circumcision has not prevented the spread of HIV in the U.S. or Israel, where the circumcision rates are high. None of the information regarding HIV transmission in Africa, regardless of how erroneously it is interpreted, should be used to support the practice of circumcising a nonconsenting newborn baby. His body is his; allow him to decide. It is his human right. If a grown man decides that he wants to surgically remove a significant and sensitive part of his own genitalia that is his right. To make that choice for another person, especially a non-consenting minor, is unethical. The procedure can be done later, it can never be undone. Foreskin “restoration” is more difficult, time consuming and imperfect (though worth the effort for those men who wish to regain their body image, sensitivity, and what was taken from them without their permission).

 

Intact Male Genitalia Cannot Be Improved Upon

The uninterrupted bonding and nursing that occurs between mother and whole, normal, intact child is the foundation for healthy children and families. These children rarely have significant illnesses prior to six months of age. The early months of life are the most precarious for unhealthy children. The first erections of a baby in utero and the intact newborn are a sensual pleasure, not, as is the case of the circumcised baby, a painful source of distress. These contrasting experiences are a precedent for a toddler, experiencing his genitals with a natural and gentle retraction of his foreskin through touch and play.

 

The foreskin in the mature male serves multiple purposes that are lost with circumcision. It contains thousands of nerve endings that communicate messages to the sympathetic and parasympathetic nervous systems, which profoundly affect sexual response. It protects the mucosal membrane and sensitivity of the glans. It maintains elasticity and flexibility of penile shaft skin. These dramatically affect sexual function and experience for men and their female partners, allowing sex to be experienced as it was designed to be.

From the perspective of Asian medicine, circumcision removes the yin (female) aspect of the male genitals, much like female circumcision removes the yang (male) aspect of the female genitalia. Asian medicine recognizes and honors the yin within yang and the yang within yin.22

 

Circumcised men and their partners suffer from a number of handicaps in their sexual experiences. The glans is changed from a sensitive moist mucous membrane to a dry, calloused, less sensitive organ. Circumcised men suffer from a loss of penile girth and a restriction to the movement of penile shaft skin. Factored together, these influences significantly compromise the experience for both partners throughout life.

 

Thousands upon thousands of circumcised men in the United States, Canada, England, and Australia have undertaken foreskin restoration. They have regained much of what was lost for them and their partners and done their best to conquer the trauma that was inflicted upon them. They are well equipped to testify to the advantages in function that a foreskin allows and what is lost to circumcision.

 

As an intact son and circumcised restoring father, the authors are grateful that the father’s defenses were overcome and his sons remained intact. As one of the son notes, “ At no time did this difference affect our deeply bonded relationship.” Not only did this protect the sons but it also allows healing for the father, which continues to this day.

 

Conclusion

There is a preponderance of evidence and sound logic that support the preservation of the healthy, normal, intact foreskin in newborn and infant boys. Any potential benefits of non-therapeutic infant circumcision suggested by flawed research are outweighed by the risks, pain, trauma, sequelae and loss of function incurred by the surgery. Worldwide, the majority of healthcare providers recognize that non-therapeutic infant circumcision violates the fundamental medical principal, Primum No Nocere (First do no harm) and refuse to perform this surgery. It is essential to adequately educate healthcare providers and families to break the cycle of harm that non-therapeutic infant circumcision has inflicted on our sons, families and society for the past 150 years.

 

Joseph Kassel, N.D., L.Ac.
Misha Kassel, MD
Clare Loprinzi, Traditional Midwife, CPM.

 

References
1 Gleiss J, Stuttgen G. Morphologic and functional development of the skin, In: Stave U, ed Physiology of the perinatal period. Vol. 2. New York: Appleton-Century Crofts, 1970:889-906.
2 Anand K, Hickey P. Pain and its effects in the human neonate and fetus. New Eng J Med 1987:317: 1321-9
3 Goldman R, BJU International, Volume 83 Supplement 1, Pg. 93-102, Jan, 1999
4 Gunnar M, Fisch R, (4) Malone S. The effects of a pacifying stimulus on behavioral and adrenocortical responses to circumcision in the newborn. J Amer Acad Child Psychiatry 1984;23:34-Bv
5 Eskes T K A B, Home Deliveries In the Netherlands-Perinatal Mortality and Morbidity. Dept of Obstretrics and Gynecology. University Hospital Nijmegenm Geert Grootepein Zuid Int. J Gyenecol Obstet 1992 38:161-169
6 Williamson P, Willamson M. Physiologic stress reduction by a local anesthetic during newborn circumcision. Pediatrics 1983;71:40
7 Avers L, Mathur A, Kamat D, Music Therapy in Pediatrics, Clin Pediatr, 2007 Sep;46(7):57
8 Ball TM, Cortisol Circadian Rhythms and Stress Responses in Infants at Risk of Allergic Disease, Neuroimmunomodulation, 2006;13(5-6):294-300.
9 DOC, Genital Integrity Policy Statement, June 2008
10 Hodges, F. “ A Short History of Circumcision in North America, In the Physicians Own Words, An Injurious Habit Occasionally Met with in Infancy and Early Childhood”, Lancet 1860;1:344-345
11 American Academy of Pediatrics Task Force on Circumcision, 84 Pediatrics 388,390(1989)
12 Ritter, Dennison, Doctors Re-examine Circumcison, 2002Third Mellenium Publishing,Seattle,Wa
13 Nguyen DM, BAncoft E, Mascola L et al. Risk factor for neonatal Methicillin-resistant staphyloccus aureus infection in a well-infant nursey. Infect Controp Hosp Epodmiol 2007;28(4):406-11
14 Gellis SS Circumcision Am J Dis Child 1978;132:1168
15 Task Force on Circumcision. Circumcision Policy Statement. Pediatrics 1999:103(3):686-93
16 Donavan B, Bassett I, Bodsworth NJ, Malec circumcison and risk of sexually transmissible diseases in a developed nation setting. Genitourin Med 1994;70:317-320
17 Van Howe RS. Does circumcision influence sexually transmitted diseases, BJU Int. 1999;83 Suppl 1;52-62
18 Dickson NP, Van Rood T, Herbison P, Paul C, Circumcision and risk of sexually transmitted infection as a birth cohort. J Pediatr 2008;152:383-7.
19 Van Howe, British Journal of Urology, Vol 80, No 5 pg 776-782, Nov.
20 American Academy of Pediatrics Task Force on Circumcision, 84 Pediatrics 388, 390 (1989)
21 Green et al, Future HIV Therapies(2008) 2 (3), 193-199
22 Acupuncture: A Comprehensive Text, 1981, Eastland Press

 

 

 

ENOUGH IS ENOUGH

 

ASK your pediatricians and OB’s to make a stand against circumcision and join the growing numbers of physicians who are refusing.

 

For more information about circumcision, please visit: www.cirp.org/