Bioethics Discussion Blog: More on the Issue of Infant Male Circumcision

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Tuesday, July 25, 2006

More on the Issue of Infant Male Circumcision

With over 400 comments to the thread on infant male circumcision, it seems that the comments for the last 2 days are not being published on my blog. In response to those who want to keep the discussion going, I have started up this comment page. If Google's Blogger.com ever reestablishes that original page, I would advise not writing further comments there but writing only to this current page to maintain continuity. ..Maurice.

IMPORTANT NEW NOTICE: AS OF DECEMBER 9 2009, NO FURTHER COMMENTS WILL BE PUBLISHED ON THIS THREAD. YOU MAY WRITE COMMENTS, HOWEVER, ON "INFANT MALE CIRCUMCISION: CHAPTER 3" THREAD. ..Maurice.

64 Comments:

At Wednesday, July 26, 2006 1:34:00 PM, Blogger David B said...

Great, I get to start.

First of all, thank you Dr. Bernstein for facilitating the continuation of the discussion.

This is an important issue in medical ethics and I fully believe that, in due course, the profession will come to the point of disavowing RIC and wonder how it ever found it ethically and morally acceptable. In my opinion, all physicians are involved in this debate by either tacitly supporting the status quo through silence, advocating for RIC, or opposing.
The arguments against RIC are pretty persuasive.
1. We do not remove healthy tissue from babies for any other ostensible public health reason.
2. Body integrity is a basic human right. Circumcision can be done but never undone.
3. The burden of prooving a compelling case for RIC is on those who think they can improve on nature, since presumably they understand it fully.

 
At Thursday, July 27, 2006 3:00:00 AM, Anonymous Jake Waskett said...

David B,

"The arguments against RIC are pretty persuasive."

Hmm. Let's examine them and see.

"1. We do not remove healthy tissue from babies for any other ostensible public health reason."

Are there any candidate procedures with a similar risk-benefit balance, or is this a red herring?

"2. Body integrity is a basic human right. Circumcision can be done but never undone."

Is this a real human right, or an arbitrary one that has been created for the sole purpose of opposing circumcision?

"3. The burden of prooving a compelling case for RIC is on those who think they can improve on nature, since presumably they understand it fully."

That might be the case if anyone were proposing routine circumcision. However, few are, and what is in fact practiced is elective infant circumcision.

 
At Thursday, July 27, 2006 10:17:00 AM, Anonymous bob koepp said...

Jake -
I assure you that the right to bodily integrity has not been created for the sole purpose of opposing circumcision. It serves as one of the bases of the right of competent patients to refuse unwanted treatments, as well as of a woman's right to an abortion.

 
At Thursday, July 27, 2006 2:23:00 PM, Blogger David B said...

Jake (from circlist), you are back! Do you do this full-time?

 
At Thursday, July 27, 2006 4:06:00 PM, Anonymous Anonymous said...

Jake's mission is to make sure that all pregnant women circ their babies. Google him on Yahoo! You'll see his creepy tracks. He visits all the pregnancy boards and tries to get all the poor unsuspecting mums to needlessly cut their baby boys penises.:(
Ewwww.

He lives in the UK, where circ is not the norm but spends his days (via his computer) in the US where circ is more of a crisis.

The pendulum is swinging here. The circ rates continue to plummet as word spreads! :)

 
At Thursday, July 27, 2006 7:38:00 PM, Blogger David B said...

The only palusible explanation for Jake's intercontinental reach and pathological elaborations on basic logic is that it's a sexual obsession. Guys should be very careful going out on dates with him and, definitely, not sleep over.

 
At Friday, July 28, 2006 7:37:00 AM, Blogger Maurice Bernstein, M.D. said...

David B., please don't make accusations about a person themselves,debate only the person's viewpoint. Thanks. ..Maurice.

 
At Friday, July 28, 2006 11:12:00 AM, Anonymous Anonymous said...

"All is fair in love and war."

Intactivists are at war with the baby-cutting-culture, don't you know that yet?

 
At Friday, July 28, 2006 11:53:00 AM, Anonymous leestein said...

AM, Jake Waskett said...
David B,


"2. Body integrity is a basic human right."

Is this a real human right, or an arbitrary one that has been created for the sole purpose of opposing circumcision?

There are some other applicable situations. One is the issue of conjoined twins.
There are pairs of conjoined twins who have survived intact well into adulthood. The ones who have been given the choice of separation in adulthood have refused, with a single exception.
Also, the issue of intersex individuals is applicable. Such children are usually assigned to one sex or the other and surgically altered to suit.
In both cases the surgery is not medically mandated and is done for sociological reasons.
(Alice Dreger takes a good look at these issues in ONE OF US)
I would say that a case can be made that conjoined twins and intersexes have the right to bodily integrity, but the matter is ethically gray. In both cases we are dealing with birth defects. A foreskin is not a birth defect. To date I have heard no reasonable justification for removing it from an infant.

 
At Friday, July 28, 2006 12:55:00 PM, Blogger David B said...

Dr. Bernstein, I normally don't do that sort of thing. But what do you make of an individual who, when his name is searched on google, shows up with 3,440 hits advocating cosmetic surgery on the genitals of healthy, perfectly formed neonates? To me this seems like an extraordinary level of interest in other people having medically unnecessary, involuntary surgery. I believe that Jake is not involved in discussion, he's conducting a single-minded media campaign.

 
At Friday, July 28, 2006 1:26:00 PM, Anonymous Anonymous said...

via the net:

"My name is Jake Waskett. I am a 28 year old gay man, currently living in the North of England. In 2003, I was circumcised by choice".

Jake gets a choice about his penis but he crusades to make sure that other men don't.

That seems fair. :O

 
At Friday, July 28, 2006 1:26:00 PM, Blogger David B said...

The search term "Maurice Bernstein MD" yields 553 hits on google. He's a professor, has twenty five publications listed on PubMed using the search terms "bernstein m AND ethics" (he probably has many more) and is an active blogger. As a reasonably well-published professor at a medium sized university, previously at a large university, my name yields 3 hits on google.

At 3,440 hits, Jake has been really busy!

In my opinion, this has relevance to the ideal of discussing the topics not the people. Advocates such as this are a topic relevant to how the status quo is maintained despite consistent lack of support on the part of medical associations in industrialized countries.

 
At Saturday, July 29, 2006 8:45:00 AM, Anonymous Sophia Magdalene said...

First, let me say that I've been very dismayed at all the nasty comments on the old page. I would hate to meet some of these people in person, even if I DO agree with them that circ is not MEDICALLY necessary in MOST cases. That being said, please allow me to say the following:

1. To answer regarding the removal of "Healthy tissue from babies for any other...reason..." Yes, we do. If babies are born with a true extra finger or toe (with bone and blood supply, not just a "skin tag finger), it is usually removed for cosmetic reasons. Generally, there is no medical reason for its removal. If you ask the parents, the doctors, the public, they would all agree that it should be removed but there is really no medical reason for it.
2. As far as sex with circumcised vs uncircumcised men, during the act, I couldn't tell you the difference from a woman's point of view. Perhaps the man may feel there is a difference. NOTE: this does not include foreplay/afterplay when there obviously is a difference as you can manipulate a foreskin during this time manually or orally.
3. If you strongly believe that your religion requires circumcision, then you should be allowed that right. There is NO form of religion that requires FGM...it is a societal more, not a religious one.
4. Personally, I would not have my son, if I ever have one, circumcised. My family does not believe in it being done routinely. I have had 2 family members who have needed to have it done due to problems as adults, and one nephew who had it done as an infant as part of a surgery to repair his urethral opening (don't remember what the problem is called. Many of the other males in my family are intact, some are circumcised and were done as infants.
5. I do NOT think that physicians or mohels should be imprisoned for performing circumcisions. Insurance companies pay very little, if anything for a circ, so doctors certainly aren't making money on them, and, at least around here, mohels charge between $60-$100 but they maybe do 4-5/month. Contrary to Bob's numerously reiterated belief, no one is getting rich doing circs.
6. NO physician recommends ROUTINE circumcision. It is an elective (which generally means it is medically recognized but NOT medically necessary...there are many of these) procedure, done with parental consent, usually on the 2nd or 3rd day of life. I don't know of any hospital that does a circ on the day of birth anymore. The use of anesthesia varies between doctors, facilities and parental request.
7. The description of a circumcision is pretty accurate except...almost no baby has "tears trickling down" their face...most babies don't cry tears for the first month or so of life due to lack of tear creation of the tear ducts.

Sorry this is so long. I just wanted to respond to some of the myths perpetuated in some of the responses. Just as an FYI...I am a nurse, used to work in newborn nursery so assisted with circs when I worked there, currently work for an insurance company.

 
At Saturday, July 29, 2006 10:52:00 AM, Anonymous Susan said...

I had my newborn baby circumcised. I was there. He was given pain medication. He cried real tears and was extremely distressed. I was devastated by the experience.

 
At Saturday, July 29, 2006 4:46:00 PM, Blogger David B said...

Sophia, to respond:

1. It seems to me that it would generally be accepted that an extra finger or toe is a birth defect, or at least an anomaly. A foreskin is neither a birth defect or anomaly. It's normal. That part of your argument, essentially a negation of anger over a healthy perfectly formed baby being altered to suit others, doesn't hold together.
2. I am not in the position to comment.
3. I love my parents but don't accept their religion. I don't believe that adults' supernatural belief systems grant them the right to permanently alter other people's bodies. If they want to alter their own, they can have at it.
4. Excellent!
5. I don't necessarily think physicians or mohels are in the circumcision business for the money. But, there is money both in the procedures and the harvested foreskins used to make high tech skin. And this money is made by permamently altering other person's bodies without their consent. Our society seems to be generally outraged by the idea of a competent adult selling a body part but, apparently, has little issue with the harvesting of body parts from helpeless infants.
6. Au contraire. Many physicians overtly and/or indirectly steer new parents toward routine circumcision.
7. Irrelevant to the ethical issues under discussion.

I'm generally considered to be a pretty genial guy. However, I don't see any shades of gray in this issue and feel a moral duty to object.

 
At Saturday, July 29, 2006 9:44:00 PM, Anonymous leestein said...

At Saturday, July 29, 2006 8:45:38 AM, Sophia Magdalene said...



1. To answer regarding the removal of "Healthy tissue from babies for any other...reason..." Yes, we do. If babies are born with a true extra finger or toe (with bone and blood supply, not just a "skin tag finger), it is usually removed for cosmetic reasons. Generally, there is no medical reason for its removal.

This is true. I agree with David that extra digits are birth defects, whereas a foreskin is not. More often than not, supernumerary digits are malformed and dusfunctional. In rare cases where they are well-developed and functional, I think there is a real ethical question about amputating them. I'm not strongly for or against, but I think there is an argument for leaving them alone if they are not creating a medical problem.

 
At Saturday, July 29, 2006 9:50:00 PM, Blogger Maurice Bernstein, M.D. said...

David B, conclusions based on a survey of Google or PubMed is open to errors. There are obvious other "Bernstein m AND ethics" since I have never published over 25 papers. I have probably only published perhaps 4 papers total in my lifetime: on cutaneuous axone reflex, Q-fever and hyperparathryoidism..all at least 40 years ago! Yes, I had one paper on hospital ethics committees about 7 years ago. ..Maurice.

 
At Sunday, July 30, 2006 6:36:00 AM, Blogger David B said...

As a search term, "Jake Waskett" is surely far more specific than "m bernsein, md" which lends further support to my contention that Jake has been very busy. Obviously, I did not review all of his 3,440 hits, but the ones I reviewed at randon all were advocacy of infant circumcision. These include letters to medical journals in which he titles himself as "Indpendent researcher." My point, however is that discussion and heavy media campaigns are separate phenomena and that, when a media campaign masquerades as discussion, it is worth noting.

 
At Sunday, July 30, 2006 12:23:00 PM, Anonymous Jake Waskett said...

"My point, however is that discussion and heavy media campaigns are separate phenomena and that, when a media campaign masquerades as discussion, it is worth noting."

Interesting point, David. What are your thoughts on the following?

From: (name deleted to protect the individual's privacy)
To: (10 or so anti-circumcision mailing lists)
Subject: new link to the MD's blog
Date: Tue, 11 Jul 2006 01:42:08 -0000

let's see if this link works:

http://bioethicsdiscussion.blogspot.com/2006/07/male-circumcision-
should-it-now-be.html#comments

if it doesn't work try this:

http://bioethicsdiscussion.blogspot.com/2005/06/i-hate-doctors.html

His link to the actual circ thread is down near the bottom of the page
(about 3/4 down) via a page link that says:

"Male Circumcision: Should It Now Be A Crime?".


and:

From: (deleted)
To: (a number of anti-circ lists)
Subject: MD's blog about Circ
Date: Tue, 11 Jul 2006 20:32:53 EDT

This was sent to me. Go read. Matthew from MGMBill.org laid out a good post.
(name deleted)
====================


I tried to post this earlier and it never came up. This is an MD's blog (he is a teacher not a circumcisor). Many of his guests seem to be MD's who circ. or are in the pro-circ camp.

His thread, about 3/4 way down is called "Should Circumcision be a crime now?" You have to click on the link to read the comments from the MD's who cut children. They make me sick!!!! I wish we could get some more Intactivists on his blog......

http://bioethicsdiscussion.blogspot.com/2005/06/i-hate-doctors.html


There are several others as well. So what are your thoughts on this, David? Is it not a prime example of a media campaign masquerading as discussion?

 
At Sunday, July 30, 2006 1:53:00 PM, Anonymous Anonymous said...

I have a thought Jake:

are you a troll on all these nocirc
lists? Why?

Also, how is it that you are able to inflitrate private email's?

 
At Sunday, July 30, 2006 6:26:00 PM, Blogger Maurice Bernstein, M.D. said...

I pray that no one is motivated to make my blog and my thread pages here a mouthpiece for PROPAGANDA on EITHER side of the circumcision issue instead of a place for civil and intelligent DISCUSSION. I will NOT accept this former motivation or behavior. Those on either sice of the issue can do all the propaganda brodcasting they want on THEIR OWN BLOGS OR WEBSITES. I haven't been doing this systematically previously, but I intend to start regularly deleting messages I feel are not written in the form to support civil and intelligent discussion of the circumcision issue. Thank you. ..Maurice.

 
At Sunday, July 30, 2006 7:01:00 PM, Blogger Maurice Bernstein, M.D. said...

Moof, from the blog “A Moof’s Tale” has visited my blog and has been astounded by the one-sided expressions about infant male circumcision that has appeared here. She, as I have wondered, whether what is being written on my blog is really representative of the views of the general public or if somehow the expressions of visitors who have written here don’t provide a realistic picture of the attitudes of the general public. For this reason, she has posed the same circumcision issue on her blog and received to date the following responses. Moof has given me specific permission to publish these responses from her blog onto mine. After looking at the sequence of comments you got, it seems to me a bit different than on my blog, doesn't it? Thanks, Moof.


Sarah-Jean Says:
July 28th, 2006 at 11:33 am
I think Male Circumcision should just be standard procedure. As far as I’ve heard, it makes things cleaner, less vulnerable to infection, and helps to avoid sexual problems such as premature ejaculation.
I don’t know much on the subject, obviously, but certainly don’t think it’s mutilation or child abuse. I bet the same people that think that circumcision is child abuse are the same people who think that abortion is not murder. We don’t want to get into THAT subject though!!
I’m just going to say this; I think it’s fine and I plan on having it done to any sons I may have. It just seems like the normal, right thing to do. I’m curious to see what others have to say about the subject though…


1. Jordan Says:
July 28th, 2006 at 11:44 am
It used to be that male circumsion was thought to have health benefits including cutting down on certain types of infections and cancers. We now know that basic hygeine does the same thing. Its a matter of personal choice. certainly some will look at it is mutilation. I guess you could look at earings the same way.


2. Pattie Says:
July 28th, 2006 at 12:11 pm
Moof,
I checked out that discussion about circumsision over at Dr. Berstein’s. I had no idea that this subject was so controversial. I, like Sarah, do not know much on the subject. From the comments over on the other blog, obviously some people know ALOT about it, and have very strong opinions on this. Although I tend to think many of the commenters were the same people over and over…. For me, I had my son circumcised. I thought it would be best hygenically, and also (not to offend anyone with this comment) BUT, I personally think it looks better. Now, that being said, I do think that some type of local pain med should be used. It must be painful to the newborn and I don’t understand why pain medication wouldn’t be provided. But, I do not think it is a form of mutilation. I certainly don’t think that it should be a crime. That is an extremeist point of view.


3. Cathy Says:
July 28th, 2006 at 12:14 pm
You know Moof, I had my kids in the early 70s. There really was not much conversation about male circumcision. It was just pretty much a given that your males babies would get circumcised. Both of mine were. I have not ever heard one complaint from either of them nor their wives about it. This talk of child-abuse and genital mutilation in my opinion goes to a far extreme. We did not have our children’s penises cut off for goodness sake. We had some skin removed.
As far as that goes, my husband was circumsized. No problem there with anything whatsoever. I’ve heard these radical stories that men can’t ejaculate or have strong orgasms when they have been circumsized. That sounds laughable to me. That is so not true.


4. Flea Says:
July 28th, 2006 at 1:06 pm
Moof,
I did not read all 446 comments at Dr. Bernstein’s blog. Instead I searched the string “jew” and found several comments that upset me a great deal. It seems to me that it’s impossible to use the words “circumcision” and “abuse” in the same sentence and not to attract anti-semites.
I’ll say only this about it, and then, forgive me but I can’t continue reading this stuff; It upsets me too much: I’m offended by the suggestion that I say what I say about circs because I am a Jew and not because of I apply an unbiased interpretation of the medical literature.
best,
Flea

5. Amie Says:
July 28th, 2006 at 2:12 pm
When I was pregnant with our first, I actually looked for a reason to have our baby circumsized, but could not find one compelling enough for me to favor it. I left it up to my husband who decided NOT to even though he is.


6. OrthoDoc Says:
July 28th, 2006 at 3:09 pm
Dear Moof,
This is after a long time. Right from my student days I have been learning that circumcision is associated with a lower risk of penile carcinoma. But that was picking up stuff straight form the book. But when my approach changed to questioning material in the books, I realised that there were many factors leading to penile carcinoma. And in medicine we have learnt that development of a condition depends on the coming together of many factors. So, as much as circucision alone cannot prevent, leaving prepuce behind alone surely cannot cause cancer.
Look at these two excellent articles in wikipedia: Medical analysis of circumcision and Circumcision.
The topics are undoubtedly controversial, but in my opinion like many social customs, the choice of having one for their babies is an individual one. I would not look at it as mutilation but I, surely would not have one for my own baby!!


7. wolfbaby Says:
July 28th, 2006 at 7:58 pm
wow this is a hot topic with some… honestly… I would for the most part leave that decision up to my husband. I will say this, if the hospital refuses to give anastisa or pain control for it and my husband still wants it for our child i would make him watch the education video or the procedure with someone else… cause there is no way any child of mine is going to have a procedure like that done with out pain control…..
with that said… i know my nephew is a young pre-teen getting him to take a bath is a nightmare… argue argue and he’s old enough you have to trust that he is doing the job correctly. so my point is; even if you teach them what they should do, we all know that children have minds of there own. In the end, they will do what they will do, so the clean facter is, in my opinion, an importnat issue…


8. Dawn Says:
July 28th, 2006 at 8:02 pm
I personally believe that circumcision is the parent’s choice if it is religious, and I would never try to talk any parent out of doing this. (However, as midwives, my partners and I did encourage the 8th day circ with a mohel if the parents were agreeable..anecdotally we saw the babies coped better and there were fewer problems with bleeding, infection and stress related reactions.) However,there are no compelling reasons to do it in a medically NORMAL infant. There are medical reasons to do it in some infants and older children. Back when I had my children, I would have had it done if one had been male. Now, I don’t think I would, if I have another child, for many reasons. But my main reason would be that if it’s not medically necessary, why should I do it to my baby.


9. drcharles Says:
July 28th, 2006 at 8:14 pm
wow. 441 is quite impressive. you almost lose the argument after 20 i think.


10. Cathy Says:
July 28th, 2006 at 10:52 pm
God Moof, I just tried reading some of those 466 comments. I had to stop, like Dr. flea, this is to upsetting. I’m beginning to think the whole world might be nuts. Not because they may disagree with me but because they seem violent in their beliefs. I have problems with people who believe everyone but them and those who share their beliefs are wrong and not just wrong but that they are child abuser’s and should be punished? I could real fired up over all this. But, I read enough there to know that many many many of those comments are just the same few people.


11. Melissa Says:
July 29th, 2006 at 2:45 am
I guess we are a bit more moderate here. I have two sons who are not circed, like others I saw no compelling reason to have it done. However if I were a member of a religion that did it I would not feel like I was mutilating my sons by having it done. The female version of circumcision is completely different from male circumcision and is mutilation. With the guys all that is removed is a bit of skin, how drastic is that really?


12. Lakshmi Says:
July 29th, 2006 at 4:13 am
Moof, I think circumcision is an unnecessary procedure. Personal hygene is sufficient to prevent infections. Oriental people who do not follow Islam normally do not circumcise their boys. And I don’t think it has made a big difference.
This issue brings to my mind a movie that I saw, in which, during a riot, people belonging to a particular religion are targetted, and circumcision exposes them as belonging to that religion. It really upset me quite a bit.


13. ipanema Says:
July 29th, 2006 at 9:19 am
When my first son was born, we opted for infant circumcision but I was informed that the hospital prohibits it because it’s not effective - they had cases wherein the skin closed back.
I went back and forth to Dr. B’s site, trying to read the GM Prohibition Act. Perhaps this was in accordance with a global ban on FGM which I had just blogged a few days ago. The Bill talks more on FGM than male circumcision. I think FGM poses more of a problem than male circumcision because of the way it is done - scissors, can lids and shards of glass!
If an issue has some religious link, one has to take extra care with words, just try to be sensitive with other people’s feelings.

14. It's me, T.J. Says:
July 29th, 2006 at 2:13 pm
I have had foster children who were, and were not, circumsized. One of my foster sons, who was not circumsized, had a history of infection. On one occasion he had become so ill that he had to be hospitalized. With the regular responsibilities that come from parenting a foster child, I was then faced with making sure that this 11 year old boy did not contract another penile infection while in my care. Maybe you can imagine the emotional and personal discomfort this child felt due to his personal medical history which was compounded by his age. Add to that, being entrusted into the hands of a stranger who is charged with the intimacy of care that should come from one’s biological father and mother.
In light of the fact that infection may indeed be a rare occurance, I decided to have my son circumsized.
As a parent, if there are any life difficulties that I can prevent my children from experiencing then I am committed to exercising that power.
I am not able to make life’s pathway completely free of stones and difficulties for my children. But if there was something that I could have prevented, and my child suffered because of my lack of action, then I would be very upset with myself for not having done all that I could to prevent it.
later…


15. Ian Lidster Says:
July 29th, 2006 at 3:07 pm
On a personal note, Moof, since I am, ahem, circumsized, as were most males of my generation, I cannot for a moment understand what all the fuss and fanaticism is about. I do not feel violated, and personally I am happy it was done, since I know men who in middle age were forced to undergo circumcision and it wasn’t a pleasant experience. There are numerous health benefits to circumcision, including the fact that penile cancer is virtually unheard of in circumcized males.
Interesting to read your other comments, and a good question to pose.
Cheers, Ian


16. Sid Schwab Says:
July 29th, 2006 at 5:28 pm
Here is a good reason to consider circumcision. And, as a circumcised male and a surgeon, I can say I’ve never seen anyone who has a reason to regret the having had the procedure, and have seen several adult males who, for reasons different from the link I provided, have surely regretted not having had it.


17. Julie Says:
July 29th, 2006 at 11:14 pm
When my son was born in 1966 I did not even question the idea of circumcision. As far as I knew all males were circumcised. I was given the impression that it was healthier for males to be circumcised.
I think that people are now questioning this assumption. I think it is a good idea to question assumptions. Now there are boys that are not being circumcised. My son let me know last year that he wished I had not had him circumcised. As it was far too late to change the past I did not ask him for his reasons.
I would not class circumcision as genital mutilation but I would say it should not be done automatically. If there are reasons of faith or health for individual children to be given infant circumcision than that is a good enough reason.

 
At Sunday, July 30, 2006 11:09:00 PM, Anonymous Jen said...

I have read all of the comments that *Dr. Bernstein* elected to post here from Moof's Blog.

It is curious to me that he posted 11 pro-circ comments and only 5 anti-circ comments. 2 were neutral.

I wonder if this was intentional on his part?

 
At Monday, July 31, 2006 5:17:00 AM, Anonymous Moof said...

Jen, if you will follow Dr. Bernstein's link to the comments on my post, or follow them from here, there have been only 21 comments total, as of this time - Monday, July 31, 7:44 AM. The last, really snarky comment, arrived overnight, since Dr. Bernstein posted that cut/paste, and came to my blog from this thread.

There have only been two rude comments on the post, and I haven't deleted them because the tone and wording do the commenters' position more harm than any pro-circ argument ever could. I know that if I were anti-circ and I saw those comments, I might consider changing my position in order to not be associated with what appears to be a "lunatic fringe." It's not uncommon for reasonable people to moderate their positions when faced with extremism.

Dr. Bernstein, yes, the comments on my blog showed both sides of the argument, but for the most part, did so in a civil manner. A few of the anti-circumcision arguments caused me to stop and ponder my own position, particularly Orthodoc who has a medical background - however, even then, the source he cited (here) has the following warning at the top of the page:

"The neutrality of this article is disputed. Please see the discussion on the talk page."

I was quite interested to see, when I went to the above mentioned "talk page," that your comment thread, and the Wiki discussion page, have at least one commenter in common.

 
At Monday, July 31, 2006 8:44:00 AM, Blogger Maurice Bernstein, M.D. said...

Jen, to follow up on Moof's comments, I want you to know that when I prepared the copy and paste from Moof's blog, there were 17 comments there and I pasted them in the order they appeared on her blog.

To find a different response on another blog is very important for me. As I have stated previously, I never started this infant circumcision thread. It was begun by others on my "I Hate Doctors" thread. Whatever the reason, based on my experience as a physician, I was never aware and it was never brought to my attention regarding the intense interest in the subject of infant circumcision. So I now have learned! And I think the controversy over the issue is important..important enought to bring it to the attention of my first and second year medical students who I will be teaching beginning in mid August. I know from past experience, this subject is not discussed with the students at this phase of their education but we are involved in teaching how doctors should behave and relate to their patients.. so it is important that I bring it up. But I really needed first to know whether what I was reading on my blog was really representative of the public in general. That is why I was pleased to read the comments on Moof's blog. It clearly demonstrates a more two sided opinion by her visitors and that it is possible to take a side with civility and without vitriolic expressions and ad hominem attacks. I am getting a feeling, so far, that the magnitiude of the opposition or the intensity of expression as written to my blog may not be representative of the views of patients in general medical practice. ..Maurice.

 
At Monday, July 31, 2006 10:58:00 AM, Anonymous Jen said...

"I am getting a feeling, so far, that the magnitiude of the opposition or the intensity of expression as written to my blog may not be representative of the views of patients in general medical practice."

Dr. Berstein,

There is a funny saying that goes something like this:

If you are not outraged, you are not paying attention.

I suspect that alot of people in America just don't know too much about circumcision yet. Like alot of things, many people just don’t stop to think too much about it unless they are directly challenged with it. It may be one of those cultural habits of ours that we continue to engage in without any real in-depth thought.

Circumcision certainly can be a hot topic of debate once you get going with it. Any topic about human ethics can always get heated. Look at the abortion issue as an example. There is a ‘lunatic fringe’ there too. People call it murder!

I do believe that there are many more people out there debating the ethics of infant circumcision in a calmer manner. Just like the abortion issue. They may not all be represented at this Blog, but that doesn’t mean that they don’t exist.

 
At Monday, July 31, 2006 12:07:00 PM, Anonymous leestein said...

"Jen said...

There is a funny saying that goes something like this:

If you are not outraged, you are not paying attention."

This is very well spoken. The majority of parents in the US continue to circumcise their sons because our culture is habituated to it. Until now no one has thought to question it. Parents evidently believe that if this has been standard procedure for so long, there must be a good reason for it, so they unthinkingly agree to it. They haven't realized that the emperor has no clothes.
Consider this comment:

"Sarah-Jean Says:

I think Male Circumcision should just be standard procedure. As far as I’ve heard, it makes things cleaner, less vulnerable to infection, and helps to avoid sexual problems such as premature ejaculation...
It just seems like the normal, right thing to do."

She is misinformed and illustrates my point beautifully.

The comments on Moof's blog illustrate the point that the current controversy has not reached the general public yet and that many people are still ill-informed.

It is to be hoped that blogs like this will ultimately help to better inform the public.

 
At Monday, July 31, 2006 1:40:00 PM, Blogger Maurice Bernstein, M.D. said...

Leestein wrote: "The comments on Moof's blog illustrate the point that the current controversy has not reached the general public yet and that many people are still ill-informed. It is to be hoped that blogs like this will ultimately help to better inform the public."

With that comment, I completely and heartily agree. My explanation for this would also include that there has been "a lot on the plate" for U.S. citizens to be concerned about in recent decades and that over the years, circumcision was not really a pressing issue. Now, with the voice of the opposition and equivocal evidence of medical benefit it still might be of more concern. However, I think there is still more attention to the war in Iraq and the loss of jobs by many folks as currently more worrisome in the day by day considerations. ..Maurice.

 
At Monday, July 31, 2006 1:48:00 PM, Anonymous Jen said...

"My explanation for this would also include that there has been "a lot on the plate" for U.S. citizens to be concerned about in recent decades and that over the years, circumcision was not really a pressing issue."

You hit it right on the head Dr. Bernstein! It's very much about our priorities as a society. When you are scratching to survive and excel in the world who on earth has time to think about these kind of "small" injustices?

I do.

 
At Monday, July 31, 2006 2:22:00 PM, Anonymous Jake Waskett said...

Some of the recent comments carry an interesting unstated assumption: that if people were fully informed, they would be strongly opposed to circumcision. Can I ask a question: why do you assume that this must be so? Is the possibility that you are misinformed yourselves really so outrageous that you can't even consider it?

 
At Monday, July 31, 2006 3:37:00 PM, Anonymous leestein said...

Now, with the voice of the opposition and equivocal evidence of medical benefit it still might be of more concern... Maurice

I would add that it was likely the outcry over female circumcision in Africa that was the wake-up call that made people start to question what we are doing to our own children. These questions are long overdue and more should be asking them.

 
At Monday, July 31, 2006 4:29:00 PM, Blogger Dan Blackham said...

Jake Waskett said... "Some of the recent comments carry an interesting unstated assumption: that if people were fully informed, they would be strongly opposed to circumcision."

Jake, can you name any other surgery that doctors will perform on children that does not have a significant NET medical benefit and does not correct a congenital condition?

Please correct me if I am wrong, but to the best of my knowledge elective, non-therapeutic circumcision is the ONLY surgery that doctors will perform on children that does not have a significant NET medical benefit or correct a congenital condition.

Jake Waskett said... "Can I ask a question: why do you assume that this must be so?"

Because infant circumcision is NOT medically necessary according to every professional medical organizations that has an official policy on circumcision

Because a male's foreskin is the only normal, healthy part of a child's body that a doctor will amputate without a valid medical indication

Because a male's foreskin is the only normal, healthy part of a child's body that a doctor will amputate for cultural or religious reasons

Jake Waskett said... "Is the possibility that you are misinformed yourselves really so outrageous that you can't even consider it?"

If you or someone else can name any other surgery that doctors will perform on children that does not have a significant NET medical benefit and does not correct a congenital condition, I would reconsider.

 
At Monday, July 31, 2006 5:22:00 PM, Anonymous Jen said...

"the war in Iraq and the loss of jobs by many folks as currently more worrisome in the day by day considerations. ..Maurice."


Pondering human ethics is indeed a luxury of time that most people can’t afford to do. It is quite interesting to watch the “genital integrity” campaign progress. I have been reading that this issue is quite explosive within American family units. The subject has even permeated the Jewish community as well. It is causing a lot of strife within families of all demonitations. There are national court cases going on right now to support this. Divorced parents are fighting about it in court. Parents are suing doctors after they are pursuaded by compelling evidence against the practice. Young men are suing hospitals and medical staff who circumcised then without their consent.

I think that all of this is indictive of a trend. More and more people are clearly challenging circumcision. There is a rather large and undeniable crowd of people talking about ”genital integrity”. They are in DC, they have a national conference every year that draws thousands I am told. They have offices all over the country too (www.nocirc.org, see:‘Regional Centers’).

It certainly does appear that the status quo is being challenged. Stagnant thought-patterns and out-dated thinking are never ever good. It is always important to think critically and examine our actions closely instead of following the crowd blindly.

 
At Monday, July 31, 2006 7:17:00 PM, Anonymous Anonymous said...

Jen said:

"It certainly does appear that the status quo is being challenged. Stagnant thought-patterns and out-dated thinking are never ever good. It is always important to think critically and examine our actions closely instead of following the crowd blindly."

Well said, my dear! It's about time the US catches up with the rest of the world when it comes to the "de-medicalization" of infant male circumcision. Canada, Austrailia, Britan have all dropped the non-therapeutic surgery like a stone in the last half century. Europe had never adopted it at all. And as far as I know, there are no penile epidemics occuring in any of these countries. Why is the US so insular in their views on this subject?

As a side note, I noticed that the link I had posted to the AAP's Committee on Bioethics policy on Informed Consent, Parental Permission and Assent is now restricted. Would you happen to have any idea as to why this would be, Dr. Bernstein?

http://aappolicy.aappublications.org/cgi/reprint-embargo/pediatrics;95/2/314.pdf

Thankfully, it is reproduced here:

http://www.cirp.org/library/ethics/AAP/

Cindy

 
At Monday, July 31, 2006 9:39:00 PM, Blogger Dan Blackham said...

July 21, 2006, Maurice Bernstein, M.D. said... "I can tell you one behavior of physicians I am against and that is the medicalization of cosmetic surgery done for aesthetic reasons. Presumably, all these examples you gave would be procedures I would classify as aesthetic procedures."

Thank you for the response. Other than removing birthmarks and pinning ears, what other cosmetic surgery will doctors perform on infants for aesthetic reasons?

Maurice Bernstein, M.D. said... "Therefore if there is definitely proven to be no medical benefit from male circumcision at any stage of life, I would be against physicians performing simply cosmetic circumcision for social or religious reasons and not for medical pathology."

Do you mean a proven NET medical benefit or just a medical benefit independent of the risks and harms?

A proven medical benefit is not a sufficient condition for surgery on a child to be ethical. For the surgery to be ethical there must be a significant NET medical benefit. In other words, the medical benefits of the surgery must significantly outweigh the medical risks and harms of the surgery.

Maurice Bernstein, M.D. said... "However, the medical profession in the United States has not given up on aesthetic cosmetic surgery and I suspect unless there appears a series of studies which show unequivocally that there is no medical benefit from infant male circumcision, as with aesthetic cosmetic surgery, in general, it will continue for a while longer. At present, I am also awaiting those results."

I was not aware that doctors perform aesthetic cosmetic surgery on infants other than removing birthmarks and pinning ears.

There is a broad consensus in the medical community that the small potential medical benefits of infant circumcision are about equal to the medical risks and harms. In other words, the small potential medical benefits of infant circumcision do NOT significantly outweigh the medical risks and harms.

 
At Monday, July 31, 2006 10:43:00 PM, Blogger Maurice Bernstein, M.D. said...

What I meant was NO medical benefit. I didn't write anything about an operation with SOME medical benefits but relative to risks. Reconstructing normal appearance from significant congenital deformities, I would consider a medical benefit. Mammoplasty, for personal appearance reasons independent of any disease of the breasts, I would consider as not a medical benefit. However, there are other physicians who would readily take an opposing view. ..Maurice.

 
At Tuesday, August 01, 2006 2:08:00 AM, Blogger Dan Blackham said...

Maurice Bernstein, M.D. said... "What I meant was NO medical benefit. I didn't write anything about an operation with SOME medical benefits but relative to risks."

I still don't understand exactly what you mean.

There are medical benefits to amputating a child's toes. Without toes a person will never get athletes foot or an ingrown toenail. However the medical benefits of toe amputation do not significantly outweigh the risks and harms.

There are medical benefits to amputating a girl's labia. Without her labia a female will never get an infection of the labia or cancer of the labia. However the medical benefits of labia amputation do not significantly outweigh the risks and harms.

Likewise there are medical benefits to amputating a boy's foreskin. However the medical benefits of foreskin amputation do not significantly outweigh the risks and harms.

Maurice Bernstein, M.D. said... "Reconstructing normal appearance from significant congenital deformities, I would consider a medical benefit."

I agree.

Maurice Bernstein, M.D. said... "Mammoplasty, for personal appearance reasons independent of any disease of the breasts, I would consider as not a medical benefit. However, there are other physicians who would readily take an opposing view."

How does that apply to non-therapeutic circumcision of minors, especially non-therapeutic circumcision of infants?

Cosmetic surgery that does not correct a significant congenital deformity should only be done with the informed consent of the patient or in the case of a minor, the informed assent of the minor patient and the informed consent of the parents.

In my opinion any doctor who performs a mammoplasty on a minor without her assent should loose his or her license to practice medicine, even if the parents requested it.

 
At Tuesday, August 01, 2006 11:29:00 AM, Anonymous Lindsay said...

I guess I just want to say that the hate-filled ad-hominen attacks make us look fanatic and crazy.

I hope that you, Maurice, and the other visitors here will be able to see past the vitriole to the real discussion and the real issues:

1. Are there real medical benefits that outweigh losing sexually functional tissues?

2. Are there real medical benefits that must be achieved in the post-partum period rather than in adulthood?

3. Whose body is it? Who has rights to make cosmetic choices about a particular body?

I don't think doctors or parents are criminal, but I do think that neither one has done much research if they choose circ for a child on medical benefits.

Performing circ on a newborn for social reasons is wrong. I don't think a parent is 'bad' or 'abusive', but I do think that they aren't thinking this through and culture will eventually change and people will stop doing it for cosmetic reasons when we have learned as a society that there are not enough compelling medical reasons.

Thanks for opening this forum to discuss this topic.

-Lindsay

 
At Wednesday, August 02, 2006 8:04:00 AM, Anonymous leestein said...

Maurice,

Here is an aspect that hasn't been discussed yet, I don't think -- cost vs utility:


Medical Decision Making, Vol. 24, No. 6, 584-601 (2004)
DOI: 10.1177/0272989X04271039
© 2004 Society for Medical Decision Making


A Cost-Utility Analysis of Neonatal Circumcision
Robert S. Van Howe, MD, MS, FAAP
Department of Pediatrics, Michigan State University College of Human Medicine, Marquette, Michigan

A cost-utility analysis, based on published data from multiple observational studies, comparing boys circumcised at birth and those not circumcised was undertaken using the Quality of Well-being Scale, a Markov analysis, the standard reference case, and a societal perspective. Neonatal circumcision increased incremental costs by $828.42 per patient and resulted in an incremental 15.30 well-years lost per 1000 males. If neonatal circumcision was cost-free, pain-free, and had no immediate complications, it was still more costly than not circumcising. Using sensitivity analysis, it was impossible to arrange a scenario that made neonatal circumcision cost-effective. Neonatal circumcision is not good health policy, and support for it as a medical procedure cannot be justified financially or medically.

 
At Wednesday, August 02, 2006 8:43:00 AM, Anonymous Jake Waskett said...

Leestein, you should be aware that Van Howe's article was criticised in an accompanying article.

Interestingly, a more recent study came to a different conclusion. "Multiple lifetime medical benefits of neonatal circumcision can be achieved at little or no cost. Because postneonatal circumcision is so expensive, its rate is the most important factor determining future cost savings from newborn circumcision." (source)

 
At Wednesday, August 02, 2006 12:14:00 PM, Anonymous leestein said...

Jake,
I read the abstract by Schoen et al. Interestingly, Edgar Schoen has written a great deal of pro-circ material, including a book and a website devoted to the benefits of RIC.
I don't want to engage in an ad hominem attack, but this falls in the same category as research papers sponsored by tobacco companies that dispute the link between smoking and cancer.
I don't have the full article available to me at the moment, but the study seems to cover neonatal vs postneonatal infants of unspecified age. Yet he includes costs of conditions such as phimosis, and penile cancer, which do not occur in infants. The figure of "medically indicated circumcision" in 9.6% of the intact males is questionable, since the necessity of circumcision is questionable in most cases. We have agreed previously that there are alternative, less radical treatments in just about every case. e.g. A case of balanitis in a child or an adult may be more costly than a neonate in terms of treating it surgically, but less costly if treated by antibiotics.

 
At Wednesday, August 02, 2006 1:25:00 PM, Anonymous Jake Waskett said...

Leestein,

"I read the abstract by Schoen et al. Interestingly, Edgar Schoen has written a great deal of pro-circ material, including a book and a website devoted to the benefits of RIC."

Certainly true. Equally interestingly, Van Howe has written at least 35 papers on the subject of circumcision, all fiercely opposed to the practice. More interesting, he is a NOCIRC activist, and has presented at NOCIRC symposia. Furthermore, the paper you mentioned was originally presented at a conference entitled "Strategies for Intactivists" (see here).

"I don't want to engage in an ad hominem attack"

Ok. Given the above, that's probably for the best. :)

"I don't have the full article available to me at the moment, but the study seems to cover neonatal vs postneonatal infants of unspecified age. Yet he includes costs of conditions such as phimosis, and penile cancer, which do not occur in infants."

The methodology is broadly equivalent to that used by Van Howe: comparing net lifetime costs involved in groups circumcised in infancy and not circumcised in infancy. A certain proportion of those not circumcised in infancy will require circumcision later on.

"The figure of "medically indicated circumcision" in 9.6% of the intact males is questionable, since the necessity of circumcision is questionable in most cases."

The figure is taken from Kaiser Permanente's records. It is not radically dissimilar to data from Finland (7.1%). Taking the percentage of young UK men circumcised, and compensating for religious groups, the figure here would appear to be about 9%. So it seems to be about right.

"We have agreed previously that there are alternative, less radical treatments in just about every case. e.g. A case of balanitis in a child or an adult may be more costly than a neonate in terms of treating it surgically, but less costly if treated by antibiotics."

Perhaps. Perhaps not. It might be cheaper in the simple case, but what about the cost of several medications that are not effective? What if multiple expensive tests are needed? What about the physician's time in interpreting these and dealing with recurrent infections? Also, how do we estimate the cost in terms of reduced effectiveness of those antibiotics in future?

I don't know the answers to these questions. Furthermore, they seem something of a distraction. The question posed is what are the cost implications of each decision in this world, not in a different world in which such problems are treated differently.

 
At Wednesday, August 02, 2006 3:49:00 PM, Anonymous Anonymous said...

Jake,

How do you debate the ethics of routine infant circumcision with a man, who by his own choice was circumcised as an adult?

Did you have a choice to have your penis modified? Should not every other man get that same choice too regarding their own body?

I know that you really like to discuss 'science and stats', as questionable as they may be, but let's try to get back to human ethics now, since this IS a Bio Ethics discussion blog. Hun?

 
At Wednesday, August 02, 2006 8:44:00 PM, Anonymous Anonymous said...

Violating the Golden Rule

George C Denniston MD

As a medical student at America's oldest hospital, Pennsylvania Hospital, I was happy to be on the obstetrics rotation. While still in college, I had heard an obstetrician speak enthusiastically about his optimistic specialty. So now I was enjoying helping to bring babies into the world. While professors provided good background information in formal lectures, my real teachers, of course, were residents only a few years older than I was. They took turns talking me through normal deliveries.
Almost every doctor can recall the joy of delivering a healthy normal infant. This joy was shattered one day when one of the residents - a resident I did not know well - said, "There are some circumcisions that need to be done - go and do them!" At the time I guess I knew what a circumcision was - but that was about it. I had certainly learned nothing about the subject in medical school. Obediently, I proceeded to the newborn nursery, where another medical student, a brilliant young Jewish man, was already waiting. I felt nervous, and he looked quite nervous, too. Strapped to a board on the long counter in front of each of us was a bawling male infant. Beside the infant was a surgical tray filled with instruments. Imagine our consternation when we found there was no one to tell us what to do. Obediently, we put on surgical gowns, then surgical gloves. Then we began to try to figure out how to use what I later learned was a Gomco Clamp.

As far as I know, I made a fairly neat job of it. But my abiding memory of that day is of my Jewish colleague. He was one of the more brilliant members of our class, and was planning to become an outstanding radiologist. As for surgery, forget it. He was all thumbs. I still remember him, standing beside me, fumbling with the complicated instruments, proceeding to use them on the helpless penis before him, all the while just shaking his head!

I look back on the only time I have ever performed any circumcisions with regret and resentment. I resent having had no opportunity to study circumcision in medical school or to consider whether I thought it a treatment for anything. I resent the resident commanding me to do it, while offering no further guidance or help. In fact, I was treated just as the medical profession treats innocent new parents today. Doctors tell them a circumcision needs to be done. Before the new parent has time to consider, it is all over. Then it is too late to say no, and everyone has to live with the consequences. I was a medical student, so a lot of the responsibility was mine. I clearly violated, all in one instant, the Golden Rule (I certainly would not have wanted that done to me); the major tenet of medical practice, First, Do No Harm; and all seven Principles of the American Medical Association's Code of Ethics. Mind you, I did not realize it then, just as unwary medical students do not realize it today. Now I know there are no valid medical indications for routine neonatal circumcision. I realize much harm can be done, evidenced by the thousands of men who have written their testimony and who have told me personally of the harm done to them. Now I also realize that I violated my patient's basic human right to enjoy his entire body intact, while all he could do was scream his tiny head off. That was some years ago, but it might just as well have been last year, or this year.

The United States is the only country in the world that, for no religious reason, severs part of the penis from the majority of its newborn males. I speak out in the hope that many parents and doctors will read this before getting swept into the cultural madness of routine neonatal circumcision. What should one do if called upon to consent to or to perform circumcisions? Just say NO! In so doing, you will be taking the only ethical position there is on this issue.

George C Denniston MD
President
Doctors Opposing Circumcision
2442 NW Market St
Seattle WA 98107
(360) 385-1882

 
At Thursday, August 03, 2006 3:23:00 AM, Anonymous Jake Waskett said...

Anonymous,

"How do you debate the ethics of routine infant circumcision with a man, who by his own choice was circumcised as an adult?"

That's easy: in exactly the same way as you would debate the subject with anyone else. :)

"Did you have a choice to have your penis modified? Should not every other man get that same choice too regarding their own body?"

I'm not entirely sure why you inflate the value of choice so much. Did you have the choice of whether to be vaccinated? Fed? Educated? Probably not, I would guess. It doesn't seem a pressing problem.

"I know that you really like to discuss 'science and stats', as questionable as they may be, but let's try to get back to human ethics now, since this IS a Bio Ethics discussion blog. Hun?"

Facts and ethics have a close relationship. It's nigh-on impossible to discuss ethics without facts.

 
At Thursday, August 03, 2006 10:27:00 AM, Anonymous Anonymous said...

"I'm not entirely sure why you inflate the value of choice so much."

I think that all of the most notable facists in human history would agree with you here! :)

I do not.

Should we have a choice over our own human sexuality? Let's stay on topic please.

Yes?
No?
Maybe?

 
At Thursday, August 03, 2006 12:44:00 PM, Blogger David B said...

Debating Jake only encourages him and gives him a platform. He can counter ANY argument. If you don;t agree with him, I suggest simply not responding to him.

 
At Thursday, August 03, 2006 5:42:00 PM, Blogger Maurice Bernstein, M.D. said...

Today, an Anonymous posted an AP news article "Comedian Joy Behar is suggesting a painful way for Mel Gibson to show he's sorry.
Behar said on 'The View' that Gibson 'needs to be welcomed into the Jewish community by a public circumcision.'"

However, what follows in the posting does not clearly separate expressions which are part of the news article and those of Anonymous.
This ambiguous type of posting, even if unintentional, is not acceptable here and I deleted the post. If Anonymous wants to repost,
be sure to put in italics, bold text or care with the placing of quotes, so that the separation is clear. ..Maurice.

 
At Friday, August 04, 2006 8:21:00 AM, Anonymous leestein said...

"Certainly true. Equally interestingly, Van Howe has written at least 35 papers on the subject of circumcision, all fiercely opposed to the practice."

For one thing, Schoen has has disingenuously cited Wolbarst's paper, ignoring the fact that it has been discredited.

"Taking the percentage of young UK men circumcised, and compensating for religious groups, the figure here would appear to be about 9%."

Most of these were to treat phimosis, which can be treated less radically. Therefore, the figure is misleading.

Perhaps. Perhaps not. It might be cheaper in the simple case, but what about the cost of several medications that are not effective?

What about the cost of later surgeries to correct complications of circumcision such as meatal stenosis?
Also, you are comparing the cost of a relatively few cases of infection with a million cases a year of infant circumcision. Assuning $200 per circumcision that comes to $200,000,000 a year ignoring treatment of complications. Do you really think that $200,000,000 a year is spent treating penile infections?

Furthermore, they seem something of a distraction. The question posed is what are the cost implications of each decision in this world, not in a different world in which such problems are treated differently.

I don't consider it a distraction. The whole point is that we should be making changes in this world. The time, money and resources squandered on a million infant circumcisions a year could be put to better use treating actual medical problems.

 
At Friday, August 04, 2006 11:20:00 AM, Anonymous Jake Waskett said...

"For one thing, Schoen has has disingenuously cited Wolbarst's paper, ignoring the fact that it has been discredited."

I know that he didn't cite Wolbarst in this particular paper. If he did elsewhere, you're welcome to go into detail and try to show that he deliberately ignored any flaws, and I'm sure that I could show deceptiveness from Van Howe, but will this really get us anywhere?

"Most of these were to treat phimosis, which can be treated less radically. Therefore, the figure is misleading."

I agree that most were probably performed to treat phimosis, but I don't agree that the figure is misleading. This is the actual probability of later circumcision.

"What about the cost of later surgeries to correct complications of circumcision such as meatal stenosis?"

Surgeries? It can be treated with home dilation. ;) But yeah, certainly these costs would need to be addressed too.

"Also, you are comparing the cost of a relatively few cases of infection with a million cases a year of infant circumcision. Assuning $200 per circumcision that comes to $200,000,000 a year ignoring treatment of complications. Do you really think that $200,000,000 a year is spent treating penile infections?"

I doubt it. But I can easily believe that HIV (very expensive drugs), UTIs, penile infections, and phimosis, as well as less common conditions such as penile cancer, BXO, and so on cost that much to treat.

 
At Friday, August 04, 2006 2:25:00 PM, Anonymous Anonymous said...

"Behar said on 'The View' that Gibson 'needs to be welcomed into the Jewish community by a public circumcision.'"


If Mel Gibson was circumcised by the Jewish community (for his ugly druken remarks) would that be considered assault and battery? It would be very fortunate for him if it was. Now only if babies could be so lucky.

 
At Friday, August 04, 2006 2:38:00 PM, Anonymous Anonymous said...

and also....

is circumcision supposed to be his punishment? WOW!

I am so glad that Ms. Behar is advising a forced circumcision for Mel as a form of punishment for his nasty remarks. That puts circ in its proper light!

Circumcision is a punishment for anyone (including children) who have to endure it by force!

Thumbs-up to Joy for making this so clear to everyone.

 
At Saturday, August 05, 2006 12:25:00 PM, Anonymous leestein said...

11:20:52 AM, Jake Waskett said...

"I know that he didn't cite Wolbarst in this particular paper."

I believe it was on his website.

"I'm sure that I could show deceptiveness from Van Howe, but will this really get us anywhere?"

Everyone has axes to grind, even supposedly objective researchers. That's why, in science, any kind of findings are subject to peer review. As we have seen, the effects of circumcision are continually being argued back and forth. Nothing has been definitely established that hasn't been contradicted by someone else's results. If RIC hadn't been culturally established for what we now know to be specious reasons (masturbation prevention)no doctor would institute it today based on what we know.

"I agree that most were probably performed to treat phimosis, but I don't agree that the figure is misleading. This is the actual probability of later circumcision."

Only given that circumcision continues to be used over less radical methods of treatment. But there is little reason it should. For instance, it has been found that phimosis responds quite well to topical steroids.


But I can easily believe that HIV (very expensive drugs), UTIs, penile infections, and phimosis, as well as less common conditions such as penile cancer, BXO, and so on cost that much to treat.

I can't. Penile cancer is extremely rare. UTIs in newborns are rare. HIV can be prevented almost 100%, very cheaply with condoms. Circumcision hasn't done much of a job of slowing it's spread in the US, now has it?
Such projections of costs are only as good as the facts you feed in.

 
At Saturday, August 05, 2006 12:47:00 PM, Anonymous leestein said...

Anonymous said...

I am so glad that Ms. Behar is advising a forced circumcision for Mel as a form of punishment for his nasty remarks.

It reflects a change in Jewish thinking as well. Whether or not Miss Behar knows it, there are Jewish groups that have realized what was being done to their infants, and have substituted a humane prayer ceremony called "Brit Sholom" for the "Brit Milah" surgery. Jews Against Circumcision have an informative website.

 
At Saturday, August 05, 2006 1:25:00 PM, Anonymous Jake Waskett said...

"Everyone has axes to grind, even supposedly objective researchers. That's why, in science, any kind of findings are subject to peer review. As we have seen, the effects of circumcision are continually being argued back and forth. Nothing has been definitely established that hasn't been contradicted by someone else's results."

Indicating that it is important to assess primary sources.

"Only given that circumcision continues to be used over less radical methods of treatment. But there is little reason it should. For instance, it has been found that phimosis responds quite well to topical steroids."

Sometimes, yes, it does. And if and when it becomes the standard treatment then it is reasonable to make such an assumption in a comparison of costs.

"I can't. Penile cancer is extremely rare."

1 in 600 to 1 in 1,400. In one million patients, that's 714 to 1667 cases.

"UTIs in newborns are rare."

1 in 50 to 1 in 100. In one million patients, that's 10,000 to 20,000 cases.

"HIV can be prevented almost 100%, very cheaply with condoms."

True, but condoms have to be used to be effective. They aren't always used. In the US approximately 0.6% are HIV+. That's 6,000 cases.

"Circumcision hasn't done much of a job of slowing it's spread in the US, now has it?"

Yes. US-based studies have generally found that circumcised men have half the risk of HIV.

"Such projections of costs are only as good as the facts you feed in."

Indeed.

 
At Tuesday, August 08, 2006 3:17:00 PM, Anonymous leestein said...

Rather than rehash what I've already said, I'm pasting this column by a pediatrician who says it far better than I could:


Should I have my new baby circumcised?

By Vincent Iannelli, M.D., your Guide to Pediatrics



Q. We are expecting a son in a few months. Should I have him circumcised?
A. This is one of the more controversial topics in Pediatrics today. The American Academy of Pediatrics, in their most recent Circumcision Policy Statement, concluded that 'data are not sufficient to recommend routine neonatal circumcision' and that 'parents should determine what is in the best interest of the child'. Since the statement didn't really come out for or against circumcision, it left many parents still asking the question, 'Should I have my son circumcised?'

It may help to look at some of the reasons that parents use to have their sons circumcised. One common reason is because 'everyone else is circumcised'. This is really not true at all. Worldwide, only about 10% of males are circumcised, and even in the United States, circumcision rates have declined from 80% in 1980 to 64% in 1995. The incidence of circumcision in the United States today is probably even less. Many online polls show an incidence of about 50%. Current data shows that the incidence of circumcision also depends on where you live in the US, with a high of 81% in the Midwest to a low of 36% in the West.

Parents sometimes want their son circumcised because they think that the uncircumcised penis is too hard to take care of and keep clean. This is not true. The uncircumcised or intact penis is relatively easy to take care. In fact, until the foreskin begins to retract, no special care is required. Once the foreskin does retract, you, or your child once he is old enough, can just gently retract the foreskin, clean the head of the penis with soap and water, rinse, and then pull the foreskin back over the head of the penis.

Another reason is that there 'are medical benefits for being circumcised', including a lower risk of urinary tract infections, penile cancer and sexually transmitted diseases. Most studies do show that uncircumcised male infants have about a 10 fold increase in UTIs, but the overall risk of an uncircumcised male infant getting a UTI is relatively low, only about 1%. Penile cancer is also more common in uncircumcised men, but this type of cancer is very rare anyway. And there is also a "small correlation between the uncircumcised male and risk for STDs".1

While these medical conditions seem to support circumcision, the American Academy of Pediatrics states that "almost all uncircumcised boys can be taught proper hygiene that can lower their chances of getting infections, cancer of the penis, and sexually transmitted diseases".2

Other conditions that only occur in uncircumcised males and which can sometimes require a later circumcision include infections of the foreskin, phimosis (inability to retract the foreskin) and paraphimosis (inability to pull the foreskin back over the head of the penis after it has been retracted).

It is also important to look at the reasons not to have a circumcision, including the risk of bleeding, pain from the procedure, infection, injury to the head of the penis, and penile sensation deficits. Children who are circumcised are also at increased risk of meatitis, or inflammation of the urethral opening.

In the end, one of the major reasons that many parents want to circumcise their child is because they want their son to look like their father, who is circumcised. Does it matter if a father is circumcised, but his children aren't? This is one area where some research is needed. There are many situations where a father and son aren't both circumcised. Premature infants are often too sick to be circumcised, and with all of the other medical issues that come up, circumcision is often not thought about. Step-fathers and adoptive parents also may not be 'the same' as their children. Does it make a difference to these children? A formal study that shows no difference would probably help to decrease the incidence of circumcisions even further.

With all that is known about the minimal medical benefits and the possible risks of circumcision, whether or not to have your son circumcision should be more of a cultural (ritual circumcision by the Jewish religion and Muslims, etc) than a medical question.

A better question would be 'Does my new baby boy need a circumcision?' The answer to that one is much easier. No, he doesn't need a circumcision.

References:

1 Lerman, Steven E, MD, Neonatal Circumcision: The Pediatric Clinics of North America: Vol 48 No 6 December 2001

2 American Academy of Pediatrics. Circumcision Information For Parents

Vincent Iannelli, M.D., is a board-certified pediatrician, fellow of the American Academy of Pediatrics, and an Associate Professor of Pediatrics at UT Southwestern Medical Center at Dallas. Dr. Iannelli's first book, "The Everything Father's First Year Book," was recently published by Adams Media.




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At Tuesday, August 08, 2006 5:08:00 PM, Anonymous Anonymous said...

Baby boy Leo weighs in:

Maybe I'd like a vote about the status of my own penis. Maybe when I am 18 we can sit down and I can listen to all of your great arguments about why I should part with this part of me. Maybe you will even persuade me. But for now can we delay this monumental decision? There is just so much controversy about its health benefits; I really need time to think about it all out for *myself*. Thank you.

 
At Tuesday, August 15, 2006 1:19:00 PM, Anonymous Lindsay said...

I could have written the previous comment (I did not). My son's name is Leo. He is 2.5 years old.

Because of the controversy and because the concept of 'medical benefits' changes from generation to generation, and because there just wasn't enough compelling reason to remove a normal part of his body, we chose to do nothing. We chose to just let nature do what nature would do: give us a son or a daughter with fingers and toes and elbows and genitals and ears and a nose.

Those are all normal bits and pieces, why would any of it need modification? If he wants to change his body once he is an adult, so be it. It's not my place to do it for him. If he chooses to modify his body later, it will be for cosmetic reasons.

Mr. Waskett's own story describes the reasons for choosing his own circumcision was for cosmetic reasons. He CHOSE for himself what was to be done with his own body and genitals.

It is wrong to seek to deprive others of that right.

I feel very strongly that Americans circumcise their children for cultural reasons. It is what we are comfortable with, it seems to be the norm. So when doctors give us gentle advice about UTI and penile cancer and phimosis, we are relieved that this cultural choice has some medical back-up. But it doesn't really. These are straw-men defenses of a cultural practice.

I hope a parent reading here may look at the issue through new eyes and see that this is about their child's rights to his own body parts, not about the cultural customs of his parents.

 
At Friday, August 18, 2006 3:08:00 PM, Anonymous Anonymous said...

Circumcising Adult Men May Slow the Spread of AIDS (Update1)
Aug. 17 (Bloomberg) -- Health officials say they may recommend widespread circumcision of adult men as a way to slow the spread of AIDS, a disease that killed 2 million people in Africa last year.

Positive findings in research results due to be reported next year could lead the World Health Organization to suggest the procedure, said Kevin De Cock, director of the agency's HIV and AIDS programs. Circumcision prevented 6 of 10 potential infections with HIV, the virus that causes AIDS, among 3,300 men in South Africa, a study found last year.

Circumcision might stop as many as 2 million infections with HIV over 10 years in sub-Saharan Africa, according to a WHO analysis. While such evidence helped researchers in Kenya enroll more than 2,000 participants in their study, widespread adoption may not be easy in all parts of Africa, said Lovemore Gwanzura, a professor at the University of Zimbabwe who studies AIDS.

``There are strong traditional beliefs that don't tie up with circumcision,'' Gwanzura said in an interview at the 16th International AIDS Conference in Toronto. ``It's going to be an uphill task.''

Circumcision may be one of the most effective short-term solutions to prevent the spread of HIV, said health officials and celebrity advocates who spoke at the conference, including former U.S. President Bill Clinton and Microsoft Corp. founder Bill Gates. It would cost about $50 per adult male.

An HIV vaccine still remains as much as a decade away and public-health officials are seeking new prevention methods in the meantime, especially for Africa, where 24.5 million people are infected with the virus.

Risks

While circumcision might reduce the risk of infection, the procedure won't provide 100 percent protection, researchers emphasized today at a media briefing during the conference.

``Whatever gains might be made through male circumcision could be wiped out by people letting down their guard,'' said Catherine Hankins, chief scientific officer for the United Nations' UNAIDS program. ``A circumcised man might think he no longer needs to use condoms. A women might think, `Oh well, he's circumcised, I don't need to raise the issues of condoms.'''

Circumcision, a tradition for Jews and Muslims, has been performed for more than 4,000 years. The earliest evidence of the practice was found in drawings in tombs in ancient Egypt depicting a man being circumcised, according to the researchers who conducted the study in South Africa.

Common Method

The most common method of circumcision in the U.S. involves pushing the foreskin away from the head of the penis and clamping it with a metal or plastic ring. The foreskin is then snipped off and the remaining skin is stitched back onto the penis. In older boys and adults, it takes up to 10 days to heal.

There are basic biological explanations for how circumcision may help prevent HIV, said WHO's De Cock, who is a physician. One reason is that the cells on the surface of the foreskin are easier for the virus to invade than those on the tip of the penis, he said.

Performing the procedure on adult men in Africa would raise several logistical and practical issues. Physicians would need to be trained to perform the procedures in developing countries, where the WHO already estimates that $7.2 billion will need to be spent over the next five years to solve shortages of health- care workers.

Safety

Pain, safety and deeply held cultural values such as perceptions of masculinity will be the biggest obstacles in persuading men to get circumcised, researchers said today during a press briefing at the conference.

While scientific evidence is incomplete on the effectiveness of circumcision in preventing HIV infection, countries need to be ready for positive results, Clinton said during a media briefing at the conference.

``We all need to be prepared for a green light that could have a staggering impact,'' Clinton said. ``It is going to be a total headache figuring out how to sell people on it and do it in a safe way.''

The key in persuading men to get circumcised will be strong education programs, said Michael Munywoki, an AIDS policy adviser for the United Nations Mission in Sudan.

Sudan

In the northern part of Sudan, where the population is mostly Muslim, boys are traditionally circumcised. In contrast, there's a strong bias against the procedure in the non-Muslim south, Munywoki said. Peer-to-peer education may be the most effective way to mobilize men and gain acceptance for such a significant cultural change.

``Circumcision is very difficult to remove from the cultural context it grew up in,'' said Carolyn Williams, head of AIDS epidemiology at the National Institutes of Health, which is funding the ongoing research. ``You're going to have difficultly going into an area of mixed cultures and telling non-Muslims that they should now look like Muslim men.''

Receptiveness to the concept probably will vary from region to region, De Cock said.

``It's a pretty radical thing to suggest,'' De Cock said. ``The gravity of the AIDS epidemic and it's recalcitrance in the face of other interventions certainly strengthened the debate.''


To contact the reporter on this story:
Marni Leff Kottle in Toronto at mkottle@bloomberg.net;
Carey Sargent in Toronto at Csargent3@bloomberg.net.

 
At Monday, August 21, 2006 8:41:00 PM, Blogger Maurice Bernstein, M.D. said...

Posted by Mel to Bioethics Discussion Blog at 8/21/2006 05:43:24 PM on the original thread on circumcision "Male Circumcision: Should It Now Be A Crime?" but which location is no longer publishing new comments. ..Maurice.


I didn't get very far in reading these comments before I stopped to post the very first thought I had after reading the proposed bill in question. I apologize if this thought has been stated by someone else.

"Congress shall make no law respecting the establishment of religion or prohibiting the free exercise thereof..." Amendment I of the U.S. Constitution

My religion does not require that my offspring be circumcised and none of them are; however, this proposal would definitely "prohibit the free exercise" of those religions that do require circumcision. It is therefore unconstitutional on its face and *that* is why Congress has not seen fit to bring it to a vote. If it passed and were signed, it would have to be struck down by the courts.


--

 
At Tuesday, August 22, 2006 12:05:00 PM, Anonymous Anonymous said...

New research suggests that removal of part or all of the female labia, may reduce the spread of AIDS significantly. The research is not politically correct, so it is not widely publicized.

When all of the skin folds on the female are removed it makes a less conducive environment for the Aids virus to breed. If both men and women were circumcised 100% of the time, our chances of wiping out AIDS completely would be strong.

 
At Tuesday, August 22, 2006 12:09:00 PM, Anonymous Anonymous said...

IF male circumcision reduces Aids by almost half, I wonder if we could reduce it even further by circumcising all females. If every man woman and child were circumcised, I think that we could wipe out AIDS completely! We need more research into female circumcision a.s.a.p. Aids is too serious of an epidemic not to consider all possibilities.

 
At Tuesday, August 22, 2006 12:12:00 PM, Anonymous Anonymous said...

Free exercise of religion should include all types of ritual blood sacrafice of young children. Period! NO QUESTIONS ASKED!

 
At Wednesday, December 09, 2009 3:51:00 PM, Blogger Maurice Bernstein, M.D. said...

IMPORTANT NOTICE: AS OF DECEMBER 9 2009 NO FURTHER POSTINGS WILL BE PUBLISHED ON THIS THREAD, HOWEVER, YOU CAN CONTINUE WRITING ON THIS TOPIC BY GOING TO THE "INFANT MALE CIRCUMCISION: CHAPTER 3" THREAD.

 

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