On August 29, Intact America launched an email campaign, inviting our followers to tell the American Academy of Pediatrics what they think about the new Circumcision Task Force’s Technical Report on Circumcision. The Report, which concedes that the purported health benefits of infant circumcision are not great enough to justify recommending it, and that the risks of circumcision have not been adequately documented, somehow concludes that the “benefits” outweigh the risks. The Report also states that the decision to circumcise baby boys, who cannot consent to have this unethical, medically unnecessary surgery performed on their bodies, should be left to the parents, and, that parents’ non-medical decision to have their child’s genitals unjustifiably altered should be abetted by having Medicaid and private insurance companies pay doctors to do the cutting.
Here’s my letter:
Dear AAP Leadership,
What were you thinking?
How can you approve a report that extols the benefits of removing the foreskin, a normal body part, without one single word devoted to the function of that body part, or why it’s there in the first place? How credible is such a report, which neglects to mention that the vast majority of the world’s men are intact (or as the report says, “uncircumcised”), and that these men do just fine?
What were you thinking when you deputized as co-author of the report a doctor who has openly boasted about circumcising his own son? The American Medical Association’s code of ethics (AMA E8.19) states: “Physicians generally should not treat themselves or members of their immediate families” … “In particular, minor children will generally not feel free to refuse care from their parents.” In 2009, the AAP’s own Committee on Bioethics clearly stated that pediatricians who treat their own children “violate a fundamental professional obligation.”* How can we trust the neutrality or the ethics of a Task Force member who so flagrantly violated his own organization’s bioethical principles?
What were you thinking when you named a specialist in adult sexually transmitted diseases to chair a Task Force to examine infant circumcision? Babies and children don’t have sex, and thus they are not at risk of contracting an STD. It seems to me, by selecting this individual as chair, the Task Force already knew what it was looking to conclude.
Would it not have been relevant for the Task Force to mention the limitations of its recommendations? Specifically, even if circumcision were to confer some protection from HIV for adult heterosexual men, as claimed by the studies cited, it was found to confer none for women, or for men having sex with men, or for intravenous drug users. And, again, it confers no protection for babies and children. Furthermore, shouldn’t the Report have mentioned that if or when an adolescent or adult becomes at risk, there are other nonsurgical ways of avoiding sexually transmitted diseases? Shouldn’t the words “safe sex” or “condom” or “abstinence” have appeared at least once in the Report?
Given the Task Force’s unequivocal conclusion that the “health benefits of newborn male circumcision outweigh the risks,” are you not concerned by the Report’s utter failure to address the risks? Specifically, how do you justify the contradictions and doublespeak in the following statements?
The true incidence of complications after newborn circumcision is unknown, in part due to differing definitions of “complication” and differing standards for determining the timing of when a complication has occurred (i.e., early or late). Adding to the confusion is the comingling of “early” complications, such as bleeding or infection, with late complications such as adhesions and meatal stenosis…. (p. 772)
Based on the data reviewed, it is difficult, if not impossible, to adequately assess the total impact of complications, because the data are scant and inconsistent regarding the severity of complications. (p. 775)
The majority of severe or even catastrophic injuries [such as] glans or penile amputation, … methicillin-resistant Staphylococcus aureus infection, urethral cutaneous fistula, glans ischemia, and death are so infrequent as to be reported as case reports (and were therefore excluded from this literature review). (p. 774)
Did you not notice any potential liability problems for the AAP and for pediatricians who circumcise that might arise as a result of the Report? For example, while discussing the Mogen clamp in its review of complications from particular circumcision techniques and tools, the Report says:
There were no specific studies of complications … because complications are rare; thus, one can only rely on available case reports of amputation. (p. 775)
No note is made of the fact that the manufacturer of the Mogen is bankrupt, due to lawsuits resulting from these “rare” complications and amputations, and that any doctor sued for an adverse outcome from a Mogen will be on his own (unless, of course, he can implicate the AAP for failing to inform him of the facts). Also, the review of techniques and tools neglects to cross-reference a mention elsewhere of “devastating burns” that can occur when electrocautery is used in conjunction with the metal Gomco clamp. Sloppy, at best.
Did anybody think to ask why no data has ever been found in the developed world showing a correlation between circumcision and disease? Since when is sub-Saharan Africa, with high rates of poverty, illiteracy, and disease, the gold-standard comparison population for American pediatrics? Did anybody wonder how it can be that Europe, where very few men have been circumcised, has lower rates of STDs and HIV than the U.S. and better overall health status, along with lower per capita health expenditures?
Has the leadership of the AAP, knowing that a Task Force was preparing recommendations about infant circumcision, noticed that medical associations in European countries are increasingly calling for doctors to refuse to perform this surgery, on the basis that it is risky, medically unnecessary, and a violation of the child’s rights? How can you completely ignore the principles and actions of your learned colleagues in other countries?
Did anybody ask the Task Force to make sure its Report was consistent with other AAP policies, including the statement by the AAP’s own Committee on Bioethics on “Informed Consent, Parental Permission, and Assent in Pediatric Practice”? The policy, still in effect, states in part:
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… [The] pediatrician’s responsibilities to his or her patient exist independent of parental desires or proxy consent. (p. 315)
In placing the burden of deciding whether to circumcise their sons squarely on the shoulders of parents (who are not medical professionals), is the Task Force Report on Circumcision contradicting this statement on Informed Consent? By referencing religion and culture as valid elements in parental decision-making (p. 759), is the Report attempting to give doctors a free pass? Religion and culture (in the American context) generally lead to circumcisions, but human rights, medical ethics and the mandate to doctors to do no harm clearly lead to leaving a boy intact.
Most important, have you not noticed the growing outcry among parents, complaining that they were duped by doctors into agreeing to allow harmful surgery to be performed on their baby boys? Are you ignoring the growing body of complaints from adult men protesting that they were robbed of an important part of their sexual anatomy, without their consent?
Are any of these considerations not relevant to the pediatrician who would strap down a helpless, screaming baby and cut off part of his penis?
I look forward to your response.
Georganne Chapin, MPhil, JD
* Committee on Bioethics, Pediatrician-Family-Patient Relationship: Managing the Boundaries. Pediatrics 124(6), Dec. 1, 2009: 1685-88.
Yesterday, the American Medical Association, whose core values are leadership, excellence, integrity and ethical behavior, announced that its membership has voted to “oppose any attempt to legally prohibit infant circumcision.”
The AMA’s president, Peter W. Carmel, M.D., was quoted as saying, “There is strong evidence documenting the health benefits of male circumcision, and it is a low-risk procedure…. [T]he AMA … will oppose any attempts to intrude into legitimate medical practice and the informed choices of patients.”
Strong evidence? Presumably, he’s talking about evidence from flawed studies conducted among adults in parts of Africa with high HIV prevalence? Even these studies show that while female to male sexual transmission of HIV might be lessened when the male is circumcised, male to female transmission actually increases. And it’s not clear what any of this has to do with newborn babies, who don’t have unprotected sex.
Health benefits? Compared to what? The foreskin is there to protect the penis, keep the glans moist, and enhance sexual pleasure throughout a man’s lifetime. Do the AMA doctors know about recent studies showing higher rates of erectile dysfunction in circumcised men than in intact men? Do they know anything about the benefits of the foreskin?
Low risk? Do Dr. Carmel and the AMA know that more than 100 babies die each year in the United States from circumcision? Do they know about the $2.3 million award made earlier this year to the family of a Georgia baby whose penis was severed and thrown into the trash after a botched circumcision? Or about Jamaal Coleson, Jr., who died in New York City this spring, following a “routine circumcision?” Or about little Eric Keefe, who bled to death following his circumcision in a South Dakota Indian Health Service hospital in 2008? Certainly, they don’t know that just this week, the blogosphere was ringing with the discussion of another post-circumcision infant death, this one allegedly from a heart attack.
Legitimate medical practice? Do the AMA members who voted to keep the United States safe for circumcisers know that most of their European colleagues believe “routine” circumcision is not legitimate – but, instead, barbaric? Have they read the call by the Royal Dutch Medical Association for doctors to refuse to surgically remove part of the genitals of babies and children, on the grounds that there is no medical reason for it, and it violates children’s rights?
Informed choices of patients? Did the AMA stop to think about WHO IS THE PATIENT who supposedly is making an “informed choice?” Answer: the BABY is the patient – not the parents – and the baby cannot consent. On the contrary, only someone with a vested interest in denying the truth can assert that babies react with anything other than terrorized, panicked protest to the ripping, crushing and severing of their tender foreskins.
In the United States and most of the modern world, cutting a normal, healthy body part from the genitals of a girl is “genital mutilation” and it’s illegal. No ethical, moral or legal rationale distinguishes boys from girls in this regard.
Shame on you, Dr. Carmel. And shame on the AMA.
In my last post, I told you about my conversation with a self-described “open-minded” pediatrician at the annual convention of the American Academy of Pediatrics. I was as distressed by his seeming ability to consider the circumcision question as a simple matter of “point of view,” as I was with the magnitude of pain and harm he had caused, and the fact that thousands of boys and men were living with the consequences. I did, however, know what he meant when he said that for him to stop performing circumcisions would be “complicated.”
If this doctor stops now, what will he tell the repeat “customers,” young parents asking him to circumcise their second or third son? What will he tell his colleagues?
If he stops, what will he tell the boys he cut who later learn that he – indeed – did put down the knife?
If he stops, and one day a young man in the small community where he practices sues him for injuries, or for lack of consent (the statute of limitations on a malpractice claim typically re-opens for a time when an individual turns 18), what defense will he offer?
On the other hand, if he doesn’t stop, how will this doctor live with his conscience – or with the consciousness that made him come to talk with us? What will he do if he botches terribly a surgery, and a baby loses half of his penis, or dies, after he knew he should stop circumcising, but didn’t?
Since the AAP conference, I’ve lost hours of sleep pondering this conversation, unable to imagine the magnitude of the suffering – one or two babies a day, week after week, month after month, year after year, strapped down and mutilated – caused by this man who took an oath to do no harm. I went online and learned that the small northeastern city where he practices has only 16,000 people. This means – again, if his numbers are correct – he has circumcised pretty much every male under the age of 25 in the community and the surrounding area.
Except his own son, that is. And by the way, what does he tell his intact son?
Let’s say your postman one day stopped by to tell you that he’d touched the genitals of all the neighborhood children, and all the children in his son’s school (though not his own child), as well as the children in the surrounding towns, over the past 25 years; and then he told you he wanted to know your point of view about that. You’d reach for the phone, and call the police.
Yet there I was, in this huge exhibit hall in Boston, standing under the bright lights of the infant formula, baby lotion, and drug companies, talking politely with a man who had cut the penises of 5000-6000 babies, but was “open-minded” and wanted to understand Intact America’s point of view.
by Georganne Chapin
Last month, I spent three days at the Intact America exhibit booth during the annual convention of the American Academy of Pediatrics. Together with my colleagues Marilyn Milos, Dan Bollinger and Amy Callan, we spoke to many, many doctors. By far, the greatest endorsement of our work came from foreign pediatricians who were nearly universally opposed to circumcising babies. I often tell doctors from the U.S. that their colleagues in Europe and Latin America do not cut babies, a fact too many find surprising.
Each year I attend, at least one conversation stands out as particularly rewarding or particularly upsetting. This year, on day two, a man who appeared to be in his early 50’s approached our booth, which was decorated with an 8 ft. banner listing “10 Reasons Why You Should Stop Circumcising Baby Boys.”
Georganne Chapin at the 2011 American Academy of Pediatrics conference in Boston
“Hi,” he said. “I came here because I’m open-minded and I want to learn.”
He went on to tell me that, in the course of his career, he’d circumcised somewhere between 5,000 and 6,000 babies, but that his own 24-year-old son wasn’t circumcised.
I was stunned. When I asked him how much money he’d thought he’d made from all those circumcisions, looking hurt he said, “I have to tell you, I’m feeling attacked.”
He tried to explain that he performs circumcisions because he’s developed a reputation for being efficient and good at it, and that all the other doctors send him their patients.
Recovering my poise somewhat, I asked the doctor why he’d left his own son intact. His reply was vague, something about the AAP’s position on circumcision at the time his son was born, the implication being that the AAP’s position had been sufficiently unsupportive of the procedure for him to decide not to circumcise his own son.
I asked him what he told the parents of the babies he circumcises. “I don’t need to tell them anything,” he said. “They come to me with their minds made up.” Did he tell them his own son is intact? No, that would violate his son’s privacy, he told me.
I finally said, “Your son is intact, and you were concerned enough to come to speak with us. The AAP still doesn’t recommend circumcision, so why don’t you stop? Our campaign this year is Put Down The Knife! You could simply stop.”
“It’s very complicated,” he answered. “I don’t think I could just stop.”
He’s right. In the absence of an external ban, or an unequivocal change in position by the feet-shuffling AAP, it is “complicated” and requires great bravery for a committed circumciser to stop.
In my next post on this topic I will explore the immense, but not insurmountable challenges the entire medical profession must face at the prospect of Putting Down The Knife! and ending the practice of circumcision.
by Georganne Chapin