The Circumcision Discussion

Elvish, BSN, DNP, RN, NP · Feb 24, 2009

I tell my new moms & dads at the hospital to give them about 6months, and it may not even take that long!!

allnurses Guide · Feb 24, 2009

I tell my new moms & dads at the hospital to give them about 6months, and it may not even take that long!!

That was true with all my sons.

steph

firstyearstudent · Feb 25, 2009

I want to preface my comments with the wish that no one take the viewpoint that I'm diss'g the poster. It's the view/opinion that irks me (not to a considerably angry amount). Also, it seems to me that student nurses need to look at how they arrive at their opinions and whether that is an accurate way to look at reasons for their decisions.

I really don't see what being a student nurse or anything about my background has to do with having an opinion about circumcision. My arguments and opinions should stand on their own (which I believe they do). A long time ago I stopped giving special credence to experts and professionals just because they call themselves an authority on a particular topic. Dr. Freedman used to give people lobotomies with an ice pick.

I'm no longer a student nurse. I've been a nurse for two years now. It's a second career for me. I'm 44 and have two sons. I have an academic background in philosophy and worked for over 10 years as a reporter prior to becoming a mom and then a nurse. My husband is Jewish and initially wanted to circumcise so we researched circumcision for well over six months, from every conceivable angle, before arriving at our decision not to circumcise our sons, despite my husband wanting them to identify as Jews.

I don't think my arguments are that outlandish or bizarre. I think the act of circumcision itself, the removal of a healthy part of an infant's body, without their consent, is actually a worse injury to them than the pain of circumcision because it is permanent. If someone said to me, you must make a choice, endure pain comparable to having your finger cut off without having your finger cut off, or have your finger magically removed without pain. Well, I'd keep the finger. My point is simply that people get so wrapped up in the pain issue, where circumcision is concerned, that they forget that the real issue is the permanent remove of part of a healthy body.

As far as walking in another person's shoes, I really can't. None of us can. Especially an infant since I know absolutely nothing about their viewpoints and preferences, because they don't have any. (Unlike say, an advanced directive.) The best I can do what I think is best for them based on my own experiences and trying to be as objective as I can and give them as much freedom as is feasible and responsible to make their own decisions. This means that I should err on the side of caution. If I was a man who was happy to be circumcised and believed that circumcision had been the best choice for me, I would hope that I still wouldn't circumcise my child because I have no idea what they would want. That would be like pre-paying my infant son's tuition at my alma mater and then insisting he go simply because it's a good school and I liked it.

We all make decisions for our children all the time, naturally, but during my research I just could not find convincing evidence that it was of a significant benefit to him. Mostly it just seemed like a perference and I didn't feel comfortable imposing my preference on my son. If he wants to get a circumcision once he is of an age to make that decision for himself, I would totally support him (hell, I'll even pay for it!).

And I would remove a tick from my child because a tick doesn't belong there, unlike his foreskin, which does belong there. If you believe that the male foreskin is like a tick, well, then, I guess you should remove it, but I think you're off-base there...

JanisM · Feb 25, 2009

This comment gave me a laugh. I remember having an ultrasound for my 2nd son (now 18 yrs old) and asking what sex he was. I was told they couldn't tell because his hands were covering his genitals. I guess it does start early!

lamazeteacher · Feb 25, 2009

I tell my new moms & dads at the hospital to give them about 6months, and it may not even take that long!!

I hope that you're not suggesting that anyone else do that. If the child does it, he'd stop if it hurt - right? Some parents go a stroke too far, causing pain and possible scarring, in the interest of "cleanliness being next to Godliness........."

rn/writer, RN · Feb 25, 2009

Originally Posted by Elvish
I tell my new moms & dads at the hospital to give them about 6months, and it may not even take that long!!

I hope that you're not suggesting that anyone else do that. If the child does it, he'd stop if it hurt - right? Some parents go a stroke too far, causing pain and possible scarring, in the interest of "cleanliness being next to Godliness........."

I don't think Elvish is referring to retracting the foreskin. I'm pretty sure she's just saying to give a male infant about six months and he'll discover every little boy's favorite toy. Lots more fun than toes.

prmenrs, RN · Feb 25, 2009

"....every little boy's favorite toy"???

Hmm. Actually, anyone w/a y-chromosone!!!

My son recently decided to get a vasectomy. While he was in the exam room w/the Urologist, he asked for a circ, too. Claimed it was too much hassle to keep it clean. I just shrugged and said "whatever".

Elvish, BSN, DNP, RN, NP · Feb 25, 2009

I don't think Elvish is referring to retracting the foreskin. I'm pretty sure she's just saying to give a male infant about six months and he'll discover every little boy's favorite toy. Lots more fun than toes.

Thank you, Mir....EXACTLY what I was saying!!

Joe12 · Mar 14, 2009

I didn't necessarily want to drag up this whole thread but I wanted to add some thoughts to this discussion and comment broadly on some points posters brought up in the last spat of posts.

1. Anesthesia and pain control. I agree with posters saying that this is the least of the concerns. Whether or not a procedure is painful doesn't factor into whether or not it is ethical to perform that procedure. The ethical practice of medicine generally says that doctors and nurses only perform medically therapeutic procedures this is waived a bit in many cases such as plastic surgeries but when done only for the sake of vanity they are generally done only on adults, so far as I am aware. In a proxy consent situation it is particularly important to only provide medically therapeutic interventions which either correct a current problem, fix a deformity, or sometimes provide a benefit that is necessary to the well being of the child (or other patient) but can't be achieved in any other, less invasive, reasonable way. Circumcision doesn't fit that category in any way and there is no objective reason to perform it.

Whether we call it mutilation or not (I do) circumcision most definitely causes damage in every case. There is cutting, there is bleeding, there is a wound that must heal, scar tissue forms. Scar tissue is by definition damage. It's only a question of how much damage and how many get more damage than expected. I've known several people who had severe complications that are bad, noticeable, but they can 'live with it'. That isn't right, there was no objective reason they had to go through that or live with it. I'd venture to say there are probably more complications then we are aware of if only because when someone 'grows up' with a problem they may not notice that it is a problem. They may think that the skin on their member is supposed to be so tight that it causes a bent erection for example or that the significant scar tissue is normal, they may not even know it's a scar.

But as most of you are aware, most medical procedures do cause damage and wounding but those woundings are justified by the therapeutic aim of the procedure. This therapeutic aim is an essential justification under conditions of proxy consent, consent for those unable to consent to the wounding for themselves. The burden of proof of justification is on the person who causes (or wishes to cause) the wounding. Consequently, a physician (or parent) would need to show that infant male circumcision was medically necessary before it would be justified. If there is equal doubt as to whether or not it is medically necessary (which is by far the most favorable position that, at present, could be taken in favor of infant male circumcision), then the procedure must not be carried out. In other words, in situations of equal doubt, the person with the burden of proof (the physician or the parent) cannot proceed.

That is not the world we currently live in though, unfortunately, though I think and hope we are moving in that direction. I think the problem is that male circumcision is given a cloak protecting it from ethical scrutiny because of its religious connections. I have little doubt it would be illegal to perform on minors today were it not tied to religion.

2. How do boys or men feel and what does that mean? I think that unless they really think about it most don't feel anything one way or the other because that is just the way things are, why dwell on something you can't change (for circumcised guys). And until recently most people (in the US) thought it was necessary which colored opinion anyway. But that doesn't make it right. Whatever you believe about circumcision one objective fact can't be denied, the only boy/man who has any say in the matter are the intact boys/men who get to make his own decision about his most personal possession. Consider that there are two groups of men, intact and circumcised.

Now of all the intact men, there will be some small group who are not happy with their state. It doesn't matter why they aren't that's just the way it is. And that is actually fine. They can get themselves circumcised. On the other side of the coin, there are going to be circumcised men who are not happy with their state. It makes no difference why they aren't happy, that's just the way it is. And that is also fine. The problem is there isn't anything they can practically do about it. So the point is leaving a boy intact puts him in the only group that always has an acceptable outcome.

Now to illustrate this point further, I'll share with you a small survey on a large teen forum. The poster who wrote message #110 explains it quite well:

"We've had poll after poll here on GovTeen. Regularly, at least 1/3 of cut guys would have preferred to have the choice. Sometimes, the number breaks 40% or approaches one-half. You can keep telling yourself that no one really minds -- but this is a personal choice that some people wish they had, for a logical reason. Why would you deny them that?"

Here is one of their polls. You will notice that the poster doesn't lie. In this admittedly small sample, about half the 'cut' guys would have preferred the choice. But, they've run similar polls before and always get the same results. My guess is that most of those 'cut' respondents are American since it is very rare outside the US similarly, the uncut guys who wished they were cut, I'd bet many of them are American and are just a bit social conscious about it. Based on the fact that (secular) circumcision is very rare outside the US and few opt for it I'd guess that the as the numbers of intact boys in the US increases you might see more discontent but again circumcised guys can't really do anything about it practically speaking.

I think that's says something very important and we should be listening. These are amongst the first group of kids to grow up with boundless information on this topic that could make an evaluation before their mind was really set. Previously, most people didn't think about it until they were about to become parents, not anymore. They can also talk to their cohorts in other countries and find out that all the myths they heard were not true and I think that is what really shapes opinion. I might add that 'foreskin restoration' is a very popular topic on those boards too.

Now I am not saying that those 50% hate their parents but they would have preferred the choice and what's wrong with that? I'll add that I've seen similar polls about 'would you circumcise your son' and the numbers usually come out much higher on the no and that is very encouraging. So those who've asked there teen or adult kids they might be ok, they might not be. Are they going to tell you about it? If they're not ok, what real option do they have anyway?

3. The issue of female circumcision came up and even the Seattle Compromise. In a nutshell, Somali immigrant parents requested their doctors to circumcise their daughters. The Somali's expressed how important it was to them for their religion, their culture, ect. The doctors resisted, the parents couldn't understand why the would circumcise boys but not girls [and neither can I]. The parents made clear that all they needed was a 'symbolic cut' a little nick, a little blood, if they couldn't get it they would go back to Somalia where it would be more extensive. The physicians acquiesce and agreed to perform this procedure. When word got out the s**t hit the fan and public pressure was so great that it was canceled. It isn't clear what happen with the children, they may have faced a worse fate in Somalia. So we protect girls from even a very simple, symbolic cut that from an objective prospective is less invasive than male circumcision but boys have no protection. How is that in any way reasonable?

There were some who said female circumcision curtails female sexual pleasure. That isn't necessarily the case. A 2002 study found that circumcised women experience sexual arousal and orgasm as frequently as uncircumcised women. The tradition may have started to try and curb female sexual arousal but so did male circumcision, particularly in Victorian America and Britain (the British have long since abandoned the procedure).

"In cases of masturbation we must break the habit by inducing such a condition of the parts as will cause too much local suffering to allow the practice being continued.", On An Injurious Habit Occasionally Met with in Infancy and Early Childhood The Lancet 1860, Vol. 1, pp. 344-345

"I refer to masturbation as one of the effects of a long prepuce [foreskin]."
The Value of Circumcision as a Hygienic and Therapeutic Measure, New York Medical Journal 1871, Vol. 14, pp. 368-374.

"[Circumcision] should be performed without anesthetic, as the pain will have a salutary effect upon the mind, especially if it be connected with the idea of punishment." Treatment for self-abuse and its effects of 1888, Iowa, p. 295 By John Harvey Kellogg.

Yep, the corn flake guy.

In parlance of those times preventing self abuse was euphemistically referred to as being 'hygienic'. Of course the meaning changed but the word stuck and now you know where the circumcised boys are more hygienic came from.

Does the fact that we think, know, that circumcision doesn't seem to impact male masturbation, actually I think it increases it, really change whether it is ethical? Does the fact that it seems, from the 2002 study, that female circumcision doesn't impact female sexual arousal or pleasure change anyones position of FGM? Is it now ok? What if we moved it into a hospital or Doctor's office, does that now make it ok? That is where most FGMs in Egypt are/were done. Here is the blog of a mother in Singapore praising her infant daughter's recent circumcision, again by a doctor. I am sure she did this out the best intentions cultural, social, religious perhaps they think it is more 'hygienic'. From an objective perspective, what is the difference between what she did and what many parents in the US did? What is the difference between these pictures and these pictures and here or here? Would your position on FGM change knowing that it doesn't impact female sexual pleasure, was done in a Drs office, and when the child was an infant? If not then why is male circumcision OK? I think the answer to that question lies in our cultural conditioning and blindness. Many people here might enjoy this article published in Australia's Medical Anthropology Quarterly, A Rose by Any Other Name? Rethinking the Similarities and Differences Between Male and Female Circumcision.

4. The HIV, STD issue. This is just ridiculous. There is a WHO recommendation but the WHO recommendation applies only to countries with high prevalence and not to countries like the US. And let me just explain to you why especially in the US, and other first world countries, the HIV argument is pretty much BS. It's also a stupid policy in Africa and will almost certainly be a long term failure but for other reasons and as others have said would require a different thread.

Anyway, to determine the probability of not becoming infected you can use the following formula:

(1 - [chance of transmission from sex])^[sexual encounters]

Now for the estimates, let's assume that there is a risk reduction of 50% for circumcised men. This is the number most often banted around by the popular media and those clowns at the UN and WHO in their reports from Africa. The probability of infection in any one encounter with an HIV positive partner varies depending on viral load, co-infection, and numerous other reasons. For example, people are most infectious soon after being infected. Infectiousness lessens after a few weeks which is one reason HIV spreads so fast in Africa, read The Invisible Cure: Africa, the West, and the Fight Against AIDS, by Helen Epstein, to find out why it's so infectious in Africa but not anywhere else.

Anyway, I've seen numbers for women infecting men range from 1/700 - 1/2500 and interestingly enough, a recent publication in the Lancent of Infectious Diseases and reported at Aidsmap, put the risk of an HIV infected woman infecting her male partner at 0.04%.

From Aidsmap:

Researchers conducting a meta-analysis of studies of the risk of HIV transmission during heterosexual sex have found that, in high-income countries prior to the introduction of combination therapy, the risk per sexual act was 0.04% if the female partner was HIV-positive, and 0.08% when the male partner was HIV-positive. However these rates were considerably higher in lower-income countries, if the source partner was in either the very early or the late stage of HIV infection, or if one partner had genital ulcer disease, write the researchers in the February issue of The Lancet Infectious Diseases.

They continue:

Pooling the data from studies in high-income countries, the researchers calculated that the risk of transmission from an HIV-positive man to his female partner was 0.08% per sexual act: in other words, it was likely to occur once every 1250 sexual acts. When it was the female partner who was HIV-positive, the male partner's risk of acquiring HIV was 0.04% per sexual act - in other words, once every 2500 sexual acts.

I bolded the last, though it isn't pertinent to the discussion, I might come back to it later. I'll only say that is so obvious I don't know why they made a point of it. It was been well known that people were more infectious in early and late stages or if they had genital ulcer diseases. Also note that they said prior to the introduction to therapy which means the true rate may actually be lower now but we'll go with it.

So based on that, we'll start the estimate that the chance of infection is 0.06% a bit higher than published in the Lancet article. That means a male having unprotected sex with an HIV positive women has about a bit more than 1 in 1800 chance of being infected. Base line risk intact men vs circumcised men 1 random heterosexual contact with an HIV+ partner.

[1 - 0.0006]^1 99.94% ~= 0.06%

[1 - 0.0006 * 0.5]^1 ~=99.97% ~= 0.03%

But the HIV distribution in the US population is about 5 in 1000 or 1/200 so, in general, there is only a 1 in 200 chance that I'll encounter someone who is HIV positive. Actually the risk is much lower but we'll discuss that in a bit. Given that as a fact, a closer estimate of the risk of becoming HIV infected after the 1 encounters is more like:

The chance of event A (encountering an HIV positive individual in the general population) * the chance of event B the likely hood of getting infected during that encounter.

1/200 * 0.0006 = 0.000003 --- 1 - 0.000003 = 99.9997% = 0.0003%

1/200 * 0.0003 = 0.000006 --- 1 - 0.0000015 = 99.99985% = 0.00015%

Of course, the number of sexual encounters is important too. For 1,000 encounters, the difference is 1.5 hundreths of a percent. That's is what circumcision bought you, big deal. Over the course of 1,000 random encounters an intact guy has 1.5 hundreths of a percent larger chance of becoming HIV positive. Circumcised guys, party on!

Of course there are some caveats to this. First, your per-exposure risk might change based on other factors and the 1/200 is quite high since 75% of the HIV positive population are men. If women only account for about 1/4 of the total, this reduces the 1/200 to between say 1/700 or 1/1000. This is what it looks like when we adjust the prevelence among women:

1/700 * 0.0006 = 0.0000008571 --- 1 - 0.0000008571 ~= 99.99992% = 0.00008%

1/700 * 0.0003 = 0.0000004286 --- 1 - 0.0000004286 ~= 99.99996% = 0.00004%

That's a whole order of magnitude. Now we're talking about a difference of 4 thousandths of a percent if we have 1,000 random partners. Party on.

For Doctors, especially in the US, to entertain the notion that circumcision is going to in anyway impact a boys chances of acquiring HIV is very misleading, not truthful, or ethical. The commonly cited 50% has to be understood in context. Circumcision as a prophylaxis for any STD is, if it is even true, over stated especially in first world countries like the US. I find courious though that it keeps getting pushed, consider HPV. Now here is something that we've been vaccinating against for over three years yet people still try and tie circumcision to HPV, why?

So yes, that was a long post but there was a lot to say. I liked what a lot of you had to say because it is really up to the medical community in general to end this. Rates are declining but we won't get to near 0 without your help. This is simply because circumcision is a pernicious practice whose myths seem to live on and on and on. No rational thinker can defend routine infant/child circumcision I just can't figure out why we are having such a problem turning it off in this country.

consult2 · Mar 14, 2009

"No rational thinker can defend routine infant/child circumcision I just can't figure out why we are having such a problem turning it off in this country."

I think we have an answer from one of the most vocal circumcision advocates--Wiswell...

http://www.circumstitions.com/Quotations.html#Wis

"I have some good friends who are obstetricians outside the military, and they look at a foreskin and almost see a $125 price tag on it. Each one is that much money.

Heck, if you do 10 a week, that's over $1,000 a week, and they don't take that much time."

Dr.Thomas Wiswell quoted in the Boston Globe June 22, 1987

morte, LPN, LVN · Mar 14, 2009

"No rational thinker can defend routine infant/child circumcision I just can't figure out why we are having such a problem turning it off in this country."
I think we have an answer from one of the most vocal circumcision advocates--Wiswell...
http://www.circumstitions.com/Quotations.html#Wis
"I have some good friends who are obstetricians outside the military, and they look at a foreskin and almost see a $125 price tag on it. Each one is that much money.
Heck, if you do 10 a week, that's over $1,000 a week, and they don't take that much time."
Dr.Thomas Wiswell quoted in the Boston Globe June 22, 1987

perhaps we should insist that the parents get the foreskin....betcha would cut done the rate a little

firstyearstudent · Mar 15, 2009

perhaps we should insist that the parents get the foreskin....betcha would cut done the rate a little

We should require that the parents watch. I saw one in nursing school and it was classically horrible -- the baby strapped down, no anesthesia, the foreskin crushed off, not cut, no comforting or breastfeeding afterward...

I'm not squeamish and it was pretty upsetting to me and it wasn't my baby. I can only imagine how freaked I would have been if I was the mom.

I watched while they lanced my newborn's foot in the ER three times for a bilirubin and he was crying like mad and trying his best to wriggle free. I was totally hormonal and started FREAKING OUT. They had to pull me away. Maybe if moms and dads had to see what really went on...