Discussing Circumcision An Elephant in the Hospital

1. Discussing CircumcisionAn Elephant in the Hospital Ryan McAllister, PhD rgm23@georgetown.edu Assistant Research Professor Physics & Oncology, Georgetown University Founding Coordinator, NotJustSkin.org

2. Wellbeing of Children and Parents

3. “It’s cleaner.” “It looks better.” Poisoning the well “Everyone does it.” Appeal to majority “I’m circumcised and I’m fine.” Anecdotal “Little snip” “useless flap of skin” Minimizing “Babies don’t feel pain/remember.” Special pleading “Doctors do it. The AAP supports it.” Appeal to authority “I can’t imagine how it’s harmful.” Appeal to ignorance Hiding an elephant

4. Social conformity • Parental preference • Prevent potential, minor problem • Prevent certain, grave problem • Therapeutic • Not allowed ever Threshold for Child Surgery Imagine the consequences for each

5. Medical best interest Your patient Consent Practitioner Responsibilities

6. What if we don’t circumcise? The child’s experience Complications Child The adult experience Is there informed consent? Survivor Parent How circumcision changes sex The Genital Cutting Context Why do practitioners perform it? Practitioner Are practitioners informed?

7. Circumcision legally questioned Circumcision always rare Circumcision now rare Tribal youth circumcision common Islamic youth circumcision common Baby circumcision common Male Genital Cutting (MGC) ca 2000

8. 1860’s–70’s, Circumcision “cures”: Epilepsy, phimosis, masturbation, paralysis, hip-joint disease, digestive disorders 1880’s–mid-1900’s, Circumcision “cures”: Spinal curvature, dementia, clumsiness, bed-wetting, rheumatic disorders, asthma, Bright’s disease, syphilis, incontinence, constipation, general nervousness, restlessness, irritability, insomnia, night terrors Moral Hygiene Medical Claims “In cases of masturbation we must … cause too much local suffering to allow the practice…” –Athol A. W. Johnson, The Lancet vol 1 (1860) How Did We Get Here?

9. TheChild’s Experience “How can it be wrong to surgically alter the genitals of a baby girl … but okay to surgically alter the genitals of a baby boy?”- SorayaMiré, Survivor, FGC Activist

10. Consensus: Prevention and Management of Pain in the Newborn Compared with older age groups, newborns • experience greater sensitivity to pain • pain has long-term consequences • lack of crying does not indicate lack of pain Sets goal to “Prevent, reduce, or eliminate the stress and pain of neonates.” –Joint statement, American Academy of Pediatrics and Canadian Paediatric Society (2000)

11. Soraya Mire, Producer, ActivistFemale Genital Cutting SurvivorVideo Credit: James Loewen

12. The Circumcision Restraint

13. “Any person who wants to subject a child to this should be required to witness one first”-Michelle Storms, MD, stopped performing circumcisions in 1988

14. Scarring always occurs • Uneven circumcision is common • 15% of examined circumcised males had penile adhesions[1] • Lymphedema [2] • Skin bridges [3-5] • Urethral fistulas, hypospadius and epispadius (a) [6-14] • Buried, concealed, and hidden penis (c) [15-27] • Penile amputation (d) [28-44] Surgical Complications - Penile Structure

15. Bleeding Difficulty Breastfeeding Meatitis Joshua Haskins died in Sept 2010 from circumcision blood loss Between 8% and 31% [48-51], usually later in the first year, but while the child is still in diapers Major Morbidity Infection Necrosis Necrotizing fasciitis, [56] scalded skin syndrome, [57] gangrene, [58] generalized sepsis, [59] meningitis. [60] Neonatal incidence 0.4% [46] Older boys as high as 10% [47] Necrosis and slough of the glans or entire penis.[52-54] Rates unknown, probably rare. Postoperative Complications (Child Data) LT Aggravated Response to Pain Permanent disability Death

16. “In a two year period, I was referred >275 newborns and toddlers with complications of neonatal circumcision… 45% required corrective surgery” Real Life Complications in DC David M. Gibbons, Pediatric Urologist, Georgetown University Hospital

17. “I didn’t do what was right for my first son…. That wasn’t done right for me, either…. When does it stop?” “It has negatively impacted all of my relationships.” “I was just a baby—I couldn’t stop them.” Circumcised father, in tears, with one circumcised and one intact son “It's like I've been raped … sexual abuse” “This act of male genital mutilation—whether it's a culture and religious or personal choice—I think is nothing but a scar of betrayal.” Circumcision and the Survivor “I can’t accept that someone did that to me.” Soyara Miré, Survivor FGC GC activist

18. The Foreskin Most erogenous tissue in male • 12-15 square inches • 10,000-20,000 nerve endings • Skin mobility • Lubrication Specializedanatomy • Frenulum • Ridged band (frenar band) • Dartos muscle Photo credit: John A. Erickson 1994

19. Intact “One of the biggest mistakes of my life….Sexual pleasure has been reduced by at least 70% both in intensity and range of sensations. –William E. Krueger, circumcised at 30 Circumcised Touch Sensitivity Comparison

20. The Foreskin Moves “The Three Zones of Penile Skin,” John A. Erickson 1994 “I've wondered what it's like to have a foreskin all my life.” –Survivor Arrows indicate the scar

21. Dustin Marquardt; Video Credit: James Loewen

22. Regret Poor consent process “I was shaking and I muttered ‘Oh God what have I done?’” –Lauren Stone, blogger, “Women Are Victims Too: A Letter to my Son” “After 63 hours of labor … the doctor asked me if I wanted him to go ahead and circumcise my baby … they didn't tell me about any pros or cons” –Claire Latham, “Circumcision Experience” "I will die hearing my baby's screams.” –Miriam Pollack, author, “Circumcision: A Jewish Feminist Perspective” Circumcision and the Parent

23. Video Credit: The Whole Network

24. Physicians want to be trusted, yet Don’t know complication incidence Trivialize complication severity Fail to state foreskin functions Omit ethical questions Perform unneeded surgery on minors Framing “Informed Consent”

25. From GU Hospital Website: • “Circumcision is considered a very safe procedure.” • “The risks include: • Bleeding • Infection • Localized redness • Injury to the penis” How Can Parents Know? No mention of foreskin sexual function

26. Painful 7-10 days • Tip raw or yellowish • Discharge up to a week • Frequent bandage change • Vit. A&D ointment to prevent adhesion Post-op complication signs • No urination within 6-8 hours • Persistent bleeding • Swelling, foul-smelling drainage, or redness around tip, worse after 3 to 5 days After the Circumcision

27. No harsh soaps or abrasives • Do not use force to retract • Foreskin becomes retractile on its own • Fewer potential health problems • A happier, healthier baby Photo Credit: drmomma.org Care of the Unaltered Penis

28. InstitutionalConflict of Interest • Tissueuse, (parents don’t know) • Research $350-$500/vial • Invitrogen • Prod codes: C0205C, C0045C, C2025C, C0015C, …. • “Magic Skin” treatment (Apligraf) • Cosmetics ~ $1000/vial • Valveta (Intercytex) • Fees - $100-300/procedure 34

29. Presenting Circumcision Do parents really have to decide if they want their children to look like them?

30. “…let out a scream I’d never heard come out of the mouth of a baby.” –Marilyn Milos, RN and founder, NOCIRC, after assisting a circumcision. Fired in 1985 for telling parents it was painful and unnecessary “I have been ridiculed, patronized, ostracized, … for my refusal to perform … circumcision.” –Michelle Storms, MD, stopped circumcising in 1988 Circumcision and the Practitioner “Medically, it doesn’t make sense… I don’t like doing the procedure. But I do it well. I’ve performed thousands of circumcisions.” –HelainLandy, MD, Head of Obstetrics, Georgetown University Hospital

31. Absent from most U.S. anatomy texts • No education about function • Taught only how to remove it • Mistaught care – “retract and wash” • Phimosis often misdiagnosed • Foreskin gradually becomes retractile Pathologizing a Healthy Organ

32. Practitioners Frame the Infant’s Experience Dr. Phyllis Marx, OB/GYN, Mohel Documentary Writer/Director Eliyahu Ungar-Sargon Cut (2007) www.cutthefilm.com

33. OB sees baby as not their patient • OBs neither follow-up nor handle complications • Pedactric Urologists handle complications Obstetricians “can neither manage their complications (2-5% incidence) nor obtain proper informed consent” –David M. Gibbons, Pediatric Urologist Georgetown University Hospital OBs don’t see complications

34. Parents say… Physicians say… Reduce penile cancer Reduce UTI occurrence Reduce cervical cancer rate in female partner Reduce FM HIV transmission • Look “like others” or “like his Dad” (#1) • “Looks better” • “Easier to keep clean” • Religion/Culture • (Physician solicitation validates option) Justifications for Genital Cutting

35. Documentary Writer/Director EliyahuUngar-Sargon Interviewing Dr. Julian Ungar-Sargon MD PhD, Neurologist Orthodox Rabbi HershyWorch Cut (2007) www.cutthefilm.com

36. Same argument used to support FGM ACS says no Irrelevant, rate ~ 1/100,000 Landmark 1986 StudyA Instructions cause UTIs Lower rate than females in all cases Principally 2002 StudyB Husbands and wives had different HPV strainsC Surgery on baby for future partner? Appearance, Cleanliness Penile Cancer Cervical Cancer UTIs Responses

37. Evidence for • 3 Randomized Controlled Trials (RCTs) • Volunteer men willing to be circumcised • Randomly circumcise half • Dubious methodology • Claim ~ 60% reduced per exposure risk • Evidence against • Most other studies • Geographic data • U.S. high circumcision and high HIV rate Circumcision as HIV prevention

38. 3 Randomized Controlled Trials (RCTs) Volunteer men willing to be circumcised Randomly circumcise half Dubious methodology Claim ~ 60% reduced per exposure risk Evidence For Evidence Against Circumcision as HIV prevention Most other studies Geographic data U.S. high circumcision and high HIV rate

39. Claims 60% per coitus HIV protection • More safe sex counseling, condoms to circumcised group • Methodological flaws in timing • 4-6 weeks, too painful for intercourse post circumcision (AAFP) • Circumcised group told “abstain at least 6 weeks” • ELISA test ~3 month “window period” seroconversion • Half the claimed protection appears in this window • Corrected results insignificant • Unusually high (4-5%) per coital transmission • No control for blood exposures, dry sex, receptive anal intercourse • Local clinic visits (strongest correlation with HIV infection) [S6] Auvert Randomized Trial

40. “Male circumcision provides a degree of protection against HIV equivalent to what a vaccine of high efficacy would have achieved.” Measels vaccine: 99% recipients become immune –Auvert et al (2006), after showing 60% protection per exposure "I have heard that if you get circumcised, you cannot catch HIV/ Aids. I don't have to use a condom or worry about all those other ways of keeping safe...” Irresponsible Representation –37 year old Mukasa, from The Monitor (Kampala, Uganda), April 10, 2007, Jan Ajwang

41. Is this good evidence? Preventative amputation? Supports FGC Belief of immunity Decreased sensitivity Decreased condom use, increased risky behavior Increased M-t-F transmission rateA US: high circumcision, high HIV rates Condoms >95X more cost-effectiveB Serious Concerns

42. Not a treatment Unnecessary “Social surgery” Tissue used commercially Pains, risks Child Misinformed, wouldn’t want children hurt HURTS Sexual loss Survivor Parent False choice, proxy consent inappropriate Recap: Bias towards cutting infants Practitioner Indoctrinated into a harmful practice Ignorant about complications, other effects

43. Professional Organizations • Protect practitioners, image Practitioners / Admins • Business, avoid controversy • OBs: “Child not my patient” Ethics Committee • “Not appropriate venue” Neglecting parents and child “Not my responsibility”

44. Yes, our responsibility Reasons for change • Care for children • Care for parents • Moral duty • Professional responsibility While in your care, you are 100% responsible for what you do to a child.

45. Stop performing • Recommend against • Medical student education • Physician reeducation • Parent education • Revise informed consent • Cease tissue use Steps

46. The following slides contain supplementary material and references. Additional Material

47. Compared with older age groups newborns • experience greater sensitivity to pain • pain has long-term consequences • lack of crying does not indicate lack of pain • Sets goal to “Prevent, reduce, or eliminate the stress and pain of neonates.” • –Joint statement, American Academy of Pediatrics and Canadian Paediatric Society Consensus: Prevention and Management of Pain in the Newborn

48. Methicillin-Resistant Staphylococcus Aureus Initial presentationpost-circumcision staphylococcalnecrotizing fasciitis After surgical debridementof infected tissue Circumcision significantly increases risk of serious infection

49. “The summer [male] circumcision season death toll in the Eastern Cape has risen to 14…” • –EC circumcision deaths: 14 South Africa’s Dispatch Online 17 Dec 2010 • “39 young men died in the last month after undergoing the rite of passage into manhood” • –S. Africa sees rise in post-circumcision deaths MSNBC 29 July 2010 Circumcision Kills Boys

50. Touch Sensitivity Results Amputated Scar Amputated Sorrels et al, BJU INTERNATIONAL 99, 864-869 (2007)