NOHARMM Position Statement on Non-Therapeutic Circumcision of Male Children

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NOHARMM Position Statement on
Non-Therapeutic Circumcision of Male Children
( rev. 11-12-97)

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INTRODUCTION

We agree with the positions of world medical associations that infant circumcision is a non-therapeutic intervention that should not be performed.(1-4) As a children's rights organization composed primarily of men subjected to childhood circumcision, we work to protect the ability of male children to enjoy the benefits of a whole and healthy body, as well as their inherent and fundamental human rights to physical integrity and self-determination. Non-therapeutic circumcision of unconsenting children is a social custom that denies these benefits and contravenes these rights. Accordingly, there is no “parental right” to subject children to non-therapeutic circumcision. We are unopposed to circumcision as a treatment of last resort for disease or injury. We assert that it is inappropriate and unethical for members of the medical profession to surgically alter the genitals of unconsenting children based on social custom, religion, tribal identity or family tradition.

VALUING INTACT GENITALS

The normal human penis, complete with a prepuce, is intact. It is not "uncircumcised," just as people with an appendix, tonsils or two breasts are not "unappendectomized," "untonsillectomized," or "unmastectomized."

A whole body is a firmer basis for sound body image than one with surgically reduced genitalia. Knowledge that one is intact and unimpaired is a sound defense against potential teasing for one's natural appearance.

ANATOMY & PHYSIOLOGY

The prepuce “provides a large and important platform for several nerves and nerve endings” and is “an important part of the sensory apparatus of the penis.”(5) The foreskin is highly innervated with specialized erogenous nerve endings of greater sophistication than the glans (penile head). Incomplete genitals cannot experience their natural potential for a full range of sensual responsiveness.

The intact human penis has a moveable foreskin that covers and protects the glans penis from injury, discomfort, and unintended stimulation. The foreskin prevents meatal ulceration, a common injury in circumcised infants that can lead to meatal stenosis.(6)

The moveable foreskin offers a fuller range of sensual experience during sexual activities than the non-intact penis. The foreskin allows the penis to glide within its own mobile sheath during intercourse,(7) stimulating the male and his partner through pressure and movement rather than undesirable friction and abrasion.

The foreskin captures the male’s natural lubricating fluid and distributes it over the glans as the foreskin retracts. This lubricates the glans for easier penetration during sexual intercourse and heightens glans sensitivity. The foreskin lessens or eliminates the need for artificial sexual lubricants.(8)

Smegma is a natural lubricant that protects the glans. It is no more or less of a health risk than female smegma. Normal hygiene by both sexes prevents smegma from accumulating and becoming offensive.(8)

A PRIMITIVE & OBSOLETE FORM OF MEDICINE

There is no scientifically valid or methodologically sound evidence that the foreskin is responsible for urinary tract infections or increased kidney failure, either in children or adults. If a causal relationship were to be proven, however, male urinary tract infections are nonetheless relatively rare, and can be effectively prevented or treated by other conservative methods.(9)

Urinary tract infections can be prevented naturally and effectively by breastfeeding.(10)

It is important for doctors and parents to know that the foreskin continues to develop through adolescence.(11) A diagnosis of penile phimosis is premature and invalid until late adolescence. Ballooning of the foreskin upon urination is not an indication for circumcision, as long as there is adequate urine stream.

Physiological problems of the foreskin, such as phimosis or paraphimosis, almost always respond well to conservative non-surgical treatments, making circumcision obsolete.(12-14)

We agree with officials of the British Medical Association, who state, "(T)o circumcise where medical research has shown other techniques to be as effective and less invasive would be unethical and inappropriate.”(15)

We concur with officials at the American Cancer Society, who state that "Perpetuating the mistaken belief that circumcision prevents cancer is inappropriate" and "…distracts the public from the task of avoiding the behaviors proven to contribute to penile and cervical cancer: especially cigarette smoking and unprotected sexual relations with multiple partners."(16)

We embrace recent research that reveals circumcision provides no discernible prophylactic benefit and may in fact increase the likelihood of STD contraction.(17) Chlamydial infection correlates strongly with the circumcised condition. We assert that more reasonable and effective means of preventing STDs include abstinence, monogamy, sex and health education programs, condom use, and good personal hygiene behaviors.

We concur with many world AIDS authorities, who remain suspicious of unproved claims of a few researchers that circumcision reduces risk of HIV infection. We share these organizations’ concerns that media repetition of these unproved claims has the dangerous potential to mislead the public into a false sense of security about circumcision as a form of AIDS prevention, and is counter-productive to AIDS education efforts.(18)

We recognize that circumcision was introduced into the Unites States as an attempt to reduce sexual pleasure (e.g., masturbation). Recent research suggests that circumcision may indeed hinder sexual response,(17) compelling circumcised men to compensate with quantity of partners (promiscuity) and variety of sexual behaviors (oral and anal sex). These behaviors may increase stimulation, but they also increase one’s risk of sexually transmitted diseases, including AIDS.

IMMEDIATE CONSEQUENCES OF INFANT CIRCUMCISION

Research demonstrates that circumcision is unquestionably painful(19) and that the severe pain of circumcision causes long-term central nervous system effects, resulting in demonstrable hypersensitivity to pain for months after the surgery.(20) It is not known when, or if, these effects disappear. It is currently unknown how this imprints the rapidly developing nervous system's processing of painful stimuli and its subsequent long-term deleterious impact.

We recognize that immediate and lingering circumcision pain impairs breastfeeding,(21) which can have a deleterious impact on child health.

Topical anesthetics may reduce, but they do not eliminate, circumcision pain.(22) To avoid subjecting children to unnecessary pain, a more ethical position for physicians would be to refuse to subject unconsenting children to non-therapeutic circumcision.

The dangers of dorsal penile nerve block (DPNB) have been minimized. While short-term consequences appear to be few, potential long-term damage to the sensory apparatus of the penis, or the developing nervous system’s response to pain, has never been studied.

Infant circumcision removes a large portion of the penile skin. Almost all of the mucosal skin is excised and, by adulthood, the total amount of deficient skin approaches or exceeds 50% of the penile shaft.(5)

The exact incidences of complications and death are unknown,(23) due to unreporting, underreporting and misreporting.

LONG-TERM CONSEQUENCES OF CIRCUMCISION

Circumcision alters the natural appearance and full functioning of the penis, resulting in what significant numbers of circumcised men regard as a disfigurement and mutilation.

Body image surveys(24) consistently find 20% of circumcised males displeased with the results of this surgery they did not choose. It is probably a conservative estimate. This percentage is likely to increase as more men become aware of how this surgery inherently damages the physiological functioning of the penis.

Hundreds of circumcised men have documented with NOHARMM their experiences of tight erections, bleeding at the scar site, inadequate sensitivity and other sexual disadvantages resulting from circumcision. NOHARMM surveys have found that widespread ignorance of male anatomy perpetuates men's lack of awareness as to how these problems are a consequence of circumcision.(25)

Circumcised men and boys have reported to NOHARMM their psychological and emotional issues arising from circumcision, such as feelings of violation, loss, mutilation and betrayal by parents and physicians. This is especially so among those who know others who were allowed to remain intact.

In the Spring of 1997, hundreds of circumcised men shared their stories of damage in letters to the American Academy of Pediatrics. This warrants investigation into the adverse long-term physical, sexual and psychological outcomes of infant circumcision on male health and well-being.

Denial of harm and other psychological coping mechanisms among circumcised individuals often makes it difficult for them to approach this subject in a rational and unbiased manner. Members of the medical community are not immune to this personal or professional denial.

Doctors who knowingly perform non-indicated amputative surgery on children should not be surprised by later expressions of anger directed at them by their former patients or by the threat of litigation.

As the percentage of intact males in the U.S. increases, parents of circumcised sons can reasonably expect their sons to be dissatisfied when they discover they have less penis than their peers. They may also come to resent that they were not afforded the opportunity to experience the benefits of unaltered genital integrity.

SOCIETY AND LAW

U.S. physicians who advocate for children's rights at home or abroad will be increasingly held accountable for failing to recognize and safeguard the male child's rights to physical integrity and self-determination.

Federal and state legislation has been enacted to protect the physical (i.e., genital) integrity of female children. Equal protection considerations demand that we affirm the inherent human right of male children to their physical integrity. Genital mutilation is not an issue of severity, but sovereignty over one’s body.

Where circumcision is customary in developing nations, boys and girls are often circumcised under rudimentary and unsanitary conditions with high rates of morbidity and mortality. Medicalizing such customs to protect children from non-medical circumcisers may reduce some risks, but does not mitigate long-term physical, sexual or psychological consequences, nor does it resolve ethical and human rights violations inherent in circumcision of healthy, unconsenting children. We maintain that physician involvement in these social customs, in developing and developed nations, is inappropriate and unethical.

Although generally our society has given parents wide latitude in decision-making for their minor children, the medical profession and society do not accord parents the right to subject their children to non-therapeutic surgical body modifications, especially those whose known damage exceeds potential for improved health.

POLICY, ETHICAL PRACTICE AND EDUCATION

In cultures with a history of childhood circumcision, medical association policies that discourage non-therapeutic circumcision can only be truly effective by implementing aggressive educational programs designed for parents and physicians.

We urge the medical community to more widely adopt existing conservative (non-surgical) alternatives to circumcision for prophylaxis and treatment of penile problems. We encourage usage and further development of more alternatives that preserve the genital integrity of the patient, regardless of age.(9)

We advocate improved curricula in medical schools to teach the anatomy, development, functions and proper care of the intact penis, as well as teaching non-surgical alternatives for the prevention and treatment of penile problems.

We encourage the use of medical textbooks that illustrate the human penis in its intact state. Illustrations of circumcised male or female genitals depict the results of cultural surgeries. These should not be used as the anatomical norm.

We call on the medical community to reassure parents that intact male hygiene is a simple matter, and is effective in the vast majority of males for the prevention of almost every penile problem that circumcision is alleged to prevent.

We strongly urge the media, in its coverage of circumcision issues, to more fully and accurately report the important lifelong functions of the male prepuce, circumcision’s adverse outcomes to male health, and the ethical and human rights implications of imposing non-therapeutic circumcision on unconsenting minors.

In cases where circumcision continues to be performed, we call for an accurate and annually updated national registry of the number of such circumcisions performed in medical facilities (hospitals, clinics and doctors’ offices); the number of circumcision-related complications (based on pre-determined diagnostic criteria); and the number of circumcision-related deaths.

We call on the health insurance industry to create a level playing field for all insurers by affirming across the board that neonatal circumcision is not to be considered a legitimate covered "benefit."

We call for an immediate cessation of solicitation for newborn circumcision by hospital staff who routinely present parents with a circumcision consent form.

We question the morality and legality of biotissue companies harvesting infant foreskins for the creation of profit-making artificial skin products.(26) We strongly advocate that alternative sources for these important products be developed. Despite potential benefits of these products, the present situation constitutes “bio-thievery” and relegates male newborns to the status of involuntary organ donors.

CONCLUSION

Non-therapeutic circumcision of unconsenting children should cease. Its inherent risks, disadvantages and significant level of dissatisfaction among those upon whom it is imposed violate fundamental medical ethics(27) and contravene human rights of the patient.(28) It is the moral duty of educated professionals, the media, religious bodies, the courts, legislators, parents and the general public to protect the health and rights of those with little or no social power to protect themselves. It is incumbent upon all segments of society to hold those institutions and individuals accountable who advocate, condone or are responsible for perpetuating removal of healthy body parts from unconsenting children.

References

Neonatal Circumcision Revisited, Fetus and Newborn Committee, Canadian Paediatric Society. Canadian Medical Association Journal, vol. 154, no. 6, March 5, 1996:769-780. back to text
Circumcision of Male Infants: Guidance for Doctors, British Medical Association, September, 1996. back to text
Position Statement: Routine Circumcision of Normal Male Infants and Boys. Australian College of Paediatrics, May 27, 1996. back to text
Guidelines for Circumcision, Australasian Association of Paediatric Surgeons, April, 1996. back to text
Taylor, J. The prepuce: specialized mucosa of the penis and its loss to circumcision. British Journal of Urology, vol. 77, 1996:291-295. back to text
Williams, N. and Kapila, L. Complications of Circumcision. British Journal of Surgery, vol. 80, no. 10, October, 1993:1231-1236. back to text
Milos, M. Circumcision:Male-Effects Upon Human Sexuality. Human Sexuality: An Encyclopedia, Vern & Bonnie Bullough (eds.), Garland Publishing, New York, 1994:119-121. back to text
Fleiss, P. The Foreskin is Necessary. Townsend Letter for Doctors and Patients (Port Townsend, WA), issue 153, April, 1996:64-68. back to text
Male Health & Genital Care:Previous Circumcision Rationale and Modern Alternatives (chart). Doctors Opposing Circumcision, 2442 N.W.Market St., Suite 42, Seattle, WA 98107. back to text
Pisacane, A. et al Breastfeeding and Urinary Tract Infection. Journal of Pediatrics, vol. 120, 1992:87-89. back to text
Newborns: Care of the Uncircumcised Penis (brochure, 1/94). American Academy of Pediatrics, Div. of Publications, 141 Northwest Point Blvd., Elk Grove Village, IL 60009. back to text
Wright, J. Treatment of Childhood Phimosis with Topical Steroid. Australia-New Zealand Journal of Surgery, vol. 64, 1994:327-328. back to text
Jorgensen, E. Treatment of Phimosis in Boys with a Potent Topical Steroid. Acta Dermato-Venereologica, vol. 73, 1993:55-56. back to text
Illingworth, R. The Normal Child: Some Problems of the Early Years and their Treatment. Churchill Livingstone, 1983:101. back to text
British Medical Association letter, "Ethical Status of Male Circumcision," dated 26 February 1996 from Dr. Fleur Fisher (Head of Ethics, Science and Information Division) to Dr. John Warren. back to text
American Cancer Society letter dated February 16, 1996 from Hugh Shingleton, M.D and Clark W. Heath, Jr., M.D. to Dr. William Oh of the American Academy of Pediatrics. back to text
Laumann, E. Circumcision in the United States. Journal of the American Medical Association, vol. 277, no. 19, April 2, 1997:1052-1057. back to text
Petition to the Task Force on Circumcision of the American Academy of Pediatrics from International AIDS Organizers, (available from NOHARMM, PO Box 460795, San Francisco, CA 94146). back to text
Anand, K.J.S. Pain and its Effects in the Human Neonate and Fetus. New England Journal of Medicine, vol. 317, no.21, 1987:1321-1329. back to text
Taddio, A. et al. Effect of Neonatal Circumcision on Pain Responses During Vaccination in Boys, Lancet, vol. 345, 1995:291-292. back to text
Marshall, R. Circumcision: II. Effects upon Mother-Infant Interaction. Early Human Development, vol. 7, 1982:367-374. back to text
Use of EMLA Prior to Circumcision. Annals of Pharmacotherapy, vol. 30, no. 11, November, 1996:1327-1330. back to text
Report of the Task Force on Circumcision of the American Academy of Pediatrics. Pediatrics, vol. 84, no. 4, August, 1989: 388-391. back to text
Awakenings: A Preliminary Poll of Circumcised Men, NOHARMM, PO Box 460795, San Francisco, CA 94146. back to text
Hammond, T. Long-Term Consequences of Neonatal Circumcision. Sexual Mutilations: A Human Tragedy. Plenum Press, New York, 1997:125-129. back to text
Rosenberg, R. Companies See $1.5b Market in Replacement Skin Products. Boston Globe, October 19, 1992:22-23. back to text
Kirkey, S. Circumcision is assault, ethicist says. Montreal Gazette, October 18, 1997:A9. back to text
Svoboda, S. Routine Infant Male Circumcision: Examining Legal and Constitutional Issues. Human Rights Advocates, vol. 27, Summer, 1996:7-9. back to text